Traumatic injuries to the portal vein: case study

BACKGROUND: Injuries to the portal vein are rare but devastating. Contemporary studies have debated the most effective management for this injury. The purpose of this case study was to provide an update on portal vein injury and add information regarding its management. METHODS: A retrospective review investigated the 10-year experience with portal vein injury in a level 1 trauma center. RESULTS: Of the 18,900 trauma patients (0.08%) evaluated during a 10-year period, 15 sustained injuries to the portal vein. All the injuries resulted from penetrating trauma, and the overall survival rate was 60% (9 of the 15 patients). Four patients died of exsanguination and two patients died later as a result of multisystem organ failure. Postoperative complications were common. Sepsis and wound infection were the most common postoperative complications, occurring in seven (78%) of the nine survivors. All the patients had associated nonvascular injuries, whereas 9 (60%) of the 15 had associated vascular injuries. Associated injuries to the other structures in the portal triad occurred in 7 (47%) of the 15 patients, and 5 (71%) of these patients survived. Survival rates by procedure were 86% for venorrhaphy and 67% for ligation. CONCLUSIONS: Injuries to the portal vein are rare. In this study, exsanguination was the main cause of death. The key to a favorable outcome is prompt control of hemorrhage with an early decision to proceed with either venorrhaphy or ligation. Ligation can be effective for the management of hemodynamically unstable patients.     

Outcome from traumatic injury of the portal and superior mesenteric veins

Traumatic injuries to the portal vein (PV) and superior mesenteric vein (SMV) are rare and carry a high mortality rate, and the best approach and method of repair is still subject to debate. The objective of the present study was to analyze risk factors for mortality in portal and superior mesenteric venous injuries. A retrospective analysis of 18 patients during a 5-year period was performed. Mechanism of injury, shock upon admission, Revised Trauma Score (RTS), Injury Severity Score (ISS), intraoperative fluid requirements, classification of venous injury severity, and associated injuries were analyzed as potential predictors of outcome. All patients were male, 9 were victims of gunshot wounds, and 11 were in shock at the time of admission. Eight patients sustained PV, and 12 sustained SMV injuries. The great majority of patients had more than 1 associated injury and 61% had an associated vascular injury. Mortality rate correlated with injury severity. Overall mortality rate was 72%. Nonsurvivors had higher ISS than survivors (24 +/-0.4 and 20 +/-1.7, respectively; p = 0.006). Uncontrollable intraoperative hemorrhage was the cause of death in 5 of 13 patients (38.4%). Six patients died during the postoperative period from complications of prolonged shock and multiple organ failure, and 2 died of sepsis. The physiologic status upon admission, the number of associated injuries, and the severity of the vascular injury are the most important factors related to mortality in PV and SMV injuries.     

Superior mesenteric venous injuries: to ligate or to repair remains the question

BACKGROUND: Superior mesenteric vein injuries are rare and incur high mortality. Given their low incidence, little data exist delineating indications for when to institute primary repair versus ligation. The purposes of this study are to review our institutional experience, to determine the additive effect on mortality of associated vascular injuries, to correlate mortality with the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) for abdominal vascular injury and to examine and define the indications and outcomes for primary repair versus ligation. MATERIAL: Retrospective 156 months study (January 1992 through December 2004) in a large Level I urban trauma center of all patients admitted with superior mesenteric vein injuries. Patients were stratified, according to surgical technique employed to deal with their injuries, into those undergoing primary repair versus ligation to determine outcomes and define the surgical indications of these methods. The main outcome measure was overall survival. Cases of survival were stratified according to surgical method: primary repair versus ligation. RESULTS: There were 51 patients with a mean Injury Severity Score of 25 +/- 12. Mechanism of injury was penetrating for 38 (76%), blunt for 13 (24%), and patients undergoing emergency department thoracotomy for 4 (8%). Surgical management was ligation for 30 (59%), primary repair for 16 (31%), and 5 (10%) patients were exsanguinated before repair. The overall survival rate was 24/50 (47%). The survival rate excluding patients undergoing emergency department thoracotomy was 51%. The survival rate excluding patients that sustained greater than 3 to 4 associated vessels injured was 65%. The survival rates of patients with superior mesenteric vein and superior mesenteric artery was 55% and superior mesenteric vein and portal vein (PV) was 40%. The survival rate of patients with isolated superior mesenteric vein injuries was 55%. Mortality stratified to AAST-OIS grade III, 44%; grade IV, 42%; and grade V, 42%. Survival rates stratified to method of management consisted of primary repair (60%) versus ligation (40%). CONCLUSIONS: SMV injuries are highly lethal. Multiple associated vessel injuries increase mortality. Mortality correlates well with the American Association for the Surgery of Trauma-Organ Injury Scale for abdominal vascular injuries. Patients undergoing primary repair have higher survival rates (63%) and lesser numbers of associated vascular and nonvascular injuries; whereas those undergoing ligation have a smaller survival rate (40%) and higher number of associated vascular and nonvascular injuries. Ligation appears to be safe and should be selected for hemodynamically unstable patients with a large number of associated injuries.     

肝移植中门静脉-内脏曲张静脉吻合在门静脉机化血栓患者的应用

目的:探讨门静脉-内脏曲张静脉吻合在门静脉机化血栓患者肝移植中的应用。方法:对门静脉和肠系膜上静脉均完全被机化血栓阻塞的7例患者实施肝移植,其中3例供体门静脉-曲张冠状静脉吻合;2例髂静脉搭桥供体门静脉和脾门旁曲张的静脉吻合;1例采用供体门静脉-胆总管前曲张静脉吻合;1例供体门静脉—曲张的胃网膜右静脉吻合。结果:7例手术全部成功。1例术后7d死于多脏器功能衰竭,但是门静脉血流一直通畅。1例术后6个月发现吻合口狭窄,术后9个月采用经皮肝穿刺门静脉支架置入治愈;其余患者分别随访12～22个月,门静脉血流均通畅,无狭窄或血栓形成,肝、肾功能正常。结论:肝移植中对门静脉和肠系膜上静脉均完全被机化血栓阻塞的患者,行供体门静脉-曲张内脏静脉吻合可取得良好疗效。     

联合门静脉/肠系膜上静脉切除的胰十二指肠术治疗胰头癌的疗效

目的:分析联合门静脉(PV)/肠系膜上静脉(SMV)切除的胰十二指肠切除术(PD)治疗胰头癌的临床疗效。方法:回顾性分析2010年1月—2013年7月手术治疗的72例胰头癌患者的临床及术后随访资料,其中40例肿瘤未累及肝总动脉、SMV、PV也无转移的患者行单纯PD术(PD组),32例单纯性累及PV/SVM的患者行联合PV/SMV切除的PD术(PV/SMV组),比较两组患者的围手术期指标及术后情况。结果:与PD组比较,PV/SMV组的手术时间(357.4min vs.289.3min)、术中出血量(851.2m L vs.641.5m L)均明显增加(均P0.05),但输血量(700.0m L vs.650.5m L),手术并发症发生率(18.75%vs.20.00%),1、2、3年生存率(50.00%vs.57.50%、31.25%vs.37.50%、21.86%vs.25.00%)以及中位生存时间(15个月vs.18个月)差异均无统计学意义(均P0.05)。结论:对于胰头癌患者应根据患者的实际情况选择适宜的手术方式,联合PV/SMV切除的PD治疗单纯性累及PV/SVM的胰头癌临床效果可靠,术后远期预后与PD手术适应证者相当。     

Traumatic injury to the portal vein.

Traumatic injuries to the upper abdominal vasculature pose difficult management problems related to both exposure and associated injuries. Among those injuries that are more difficult to manage are those involving the portal vein. While occurring rarely, portal vein injuries require specific therapeutic considerations. Between January, 1968, and July, 1974, over 2000 patients were treated operatively for abdominal trauma at the Ben Taub General Hospital. Among these patients, 22 had injury to the portal vein. Seventeen portal vein injuries were secondary to gunshot wounds, 3 to stab wounds, and 2 to blunt trauma. Associated injuries to the inferior vena cava, pancreas, liver and bile ducts were common. Three patients had associated abdominal aortic injuries, two with acute aorto-caval fistulae. Nine patients died from from failure to control hemorrhage. Eleven were long-term survivors, including two who required pancreataico-duodenectomy as well as portal venorrhaphy. Late complications were rare. The operative approach to patients with traumatic injuries to multiple organs in the upper abdomen, including the portal vein, requires aggressive management and predetermined sequential methods of repair. In spite of innumerable associated injuries, portal vein injuries can be successfully managed in a significant number of patients using generally available surgical techniques and several adjunctive maneuvers.     

A 20-year Experience with Portal and Superior Mesenteric Venous Injuries: Has Anything Changed?

ObjectivesTo identify predictive factors causing mortality in patients with injuries to the portal (PV) and superior mesenteric veins (SMV).DesignRetrospective analysis of prospectively collected data.Materials and methodsAdults admitted with blunt or penetrating PV and SMV injuries at an academic level I trauma center during a 20-year period.ResultsOf 26,387 major trauma victims admitted from 1987 through 2006, 26 sustained PV or SMV injuries (PV = 15, SMV = 11). Mechanism of injury was penetrating in 19 (73%) and 20 were in shock. Active hemorrhage occurred in 21. Most patients had associated injuries (2.9 ± 1.8/patient). Mean Injury Severity Score (ISS) was 27.8 ± 16.8. All PV injuries underwent suture repair and 27% of SMV injuries were ligated. Overall mortality was 46% (PV = 47%, SMV = 45%). Stab wounds had a lower mortality (31%) compared to gunshot wounds (67%) and blunt injuries (57%). Nonsurvivors had a higher ISS (35.8 vs. 20.9; p = 0.02), more associated injuries (3.7 vs. 2.2; p = 0.02), were older, and had active hemorrhage. Active hemorrhage (p = 0.04) was independently related to death while shock on admission (odds ratio = 6.1, p = 0.61) trended toward higher mortality.ConclusionDespite improvements in trauma care, mortality of PV and SMV injuries remains high. Shock, active hemorrhage, and associated injuries were predictive of increased mortality.     

Portal vein injuries. Noninvasive follow-up of venorrhaphy.

The authors report their experience with 14 patients with portal vein injuries (1976-1986) treated at a level I trauma center. Seven patients (50%) survived and included six of 10 patients (60%) who had venorrhaphy and one in whom the portal vein was ligated. Associated injuries were present in all the patients (mean Abdominal Trauma Index: 39.5) and accounted for the high mortality rate. Follow-up data after repair or ligation of the portal vein seldom are reported in the literature. The authors studied all three patients who survived portal venorrhaphy since 1982 by real-time ultrasonography. Patency of the repair could be established in two patients. In the third patient postvenorrhaphy thrombosis was diagnosed by ultrasonographic examination. Sequential ultrasonographic examinations demonstrated resolution of the thrombus on anticoagulant therapy. Ultrasonography provides a noninvasive and easily reproducible method of studying the portal vein after repair.     

Preoperative indications for extended pancreatectomy for locally advanced pancreas cancer involving the portal vein.

This retrospective study attempted to determine the indications for extended pancreatectomy for locally advanced carcinoma of the pancreas, in terms of postoperative prognosis. An extended pancreatectomy with portal vein or superior mesenteric vein (PV/SMV) resection and regional lymphadenectomy was performed in 35 of 50 consecutive cancers that extended into the retroperitoneal spaces and involved the PV or SMV. Among the many background factors in the 35 resected specimens, the degree of PV/SMV invasion by the cancer was most closely associated with prognosis, despite resection of all involved PV/SMV. This factor generally correlated with the preoperative findings on the portal phase of superior mesenteric arteriograph. In 17 selected patients in whom PV/SMV invasion had been angiographically both semicircular or less and 1.2 cm (1.4 cm on the film) or less in length, the 3-year survival rate was 59%. This survival rate was significantly higher than the 29% 3-year survival rate in all 35 patients (p less than 0.05). Conversely, among the 18 patients in whom invasion was angiographically either beyond semicircular or more than 1.2 cm (1.4 cm on the film) in length, there were no 1.5-year survivors, and this result was even worse than that of 15 nonresectable cases. Based on postoperative survival, the degrees of PV/SMV invasion on preoperative angiography (narrowing pattern and length) are good indicators for aggressive pancreatectomy for locally advanced pancreatic cancer.     

Traumatic superior mesenteric artery—Portal vein fistula

An interesting and rare case of traumatic superior mesenteric artery-to-portal vein arteriovenous fistula is presented. Initial operative control of the bleeding superior mesenteric artery injury required ligation of the superior mesenteric artery at its origin to prevent exsanguination in an extremely unstable patient with multiple injuries. Early postoperative visceral arteriography documented ligation of the superior mesenteric artery with a proximal superior mesenteric artery-to-portal vein arteriovenous fistula. Percutaneous catheter embolization of the arteriovenous fistula was undertaken successfully at this time. Superior mesenteric artery ligation was surprisingly well tolerated. Major arterioportal fistulas require treatment to prevent long-term complications of intestinal ischemia, portal hypertension, and cirrhosis. Although traditional treatment involves ligation of the arteriovenous fistula and arterial bypass, percutaneous embolization is becoming a viable alternative. Arteriography remains the cornerstone of diagnosis and treatment planning.     

Injuries to the portal triad

We reviewed the management and clinical course of 21 patients with extrahepatic injuries to the portal triad seen over the past 11 years at a Level I trauma center. These represented only 0.21% of patients with multiple trauma admitted during this time. Portal triad injury was never specifically diagnosed preoperatively. Extrahepatic bile duct injury occurred in 4 patients, portal vein injury in 14, and hepatic artery injury in 7; 3 patients had combined injuries. Eleven patients (52%) died, all due to uncontrolled hemorrhage from either an injured portal vein or associated intra-abdominal injuries. Management of the bile duct injuries included drainage alone, bile duct ligation, and Roux-Y hepaticojejunostomy. Survivors of portal vein injury were managed with lateral venorrhaphy. Ligation of the hepatic artery appeared to be optimal for injuries incurred by this vessel. Complications necessitating reoperation or percutaneous drainage procedures were encountered in 8 of 10 surviving patients (80%). Injuries to the portal triad are uncommon, difficult to diagnose, and technically challenging. Mortality is most directly related to uncontrolled intraabdominal hemorrhage, and salvage requires rapid control of bleeding as the first treatment priority.     

Primary venorrhaphy for traumatic inferior vena cava injuries

Primary venorrhaphy for traumatic inferior vena cava (IVC) injury has been criticized because of the potential for stenosis, thrombosis, and embolism. A retrospective study was performed to evaluate the morbidity and outcome of this method. Thirty-eight patients at our institution had traumatic injuries to the IVC between 1994 and 1999. Thirty (79%) were from firearms, five (13%) from stab wounds, and three (8%) from blunt trauma. Six patients died in the emergency department. The remaining 32 patients underwent exploratory celiotomy with 23 survivors and nine intraoperative deaths for a mortality rate of 28 per cent (nine of 32). Vascular control was achieved by manual compression in 44 per cent and by local clamping directly above and below the injury in 38 per cent. All repairs were by primary venorrhaphy, and no patient was treated with patch angioplasty or venous reconstruction. Three patients had caval ligation. Follow-up IVC imaging in 11 patients revealed that the IVC was patent in eight, narrowed in two, and thrombosed below the renal veins in one. One patient developed a pulmonary embolus. The vast majority of traumatic injuries to the IVC can be managed by direct compression or local clamping and primary venorrhaphy. Direct repairs are associated with a low thrombosis and embolic complication rate.     

Indication for the use of an interposed graft during portal vein and/or superior mesenteric vein reconstruction in pancreatic resection based on perioperative outcomes

Purpose

Combined portal vein and/or superior mesenteric vein (PV/SMV) resection with pancreatic resection sometimes leads to prolonged survival for patients with pancreatic cancer. In this study, we evaluated perioperative outcomes of patients with PV/SMV reconstruction and considered indications for the use of a graft during this procedure.

Methods

We performed PV/SMV resection with pancreatic resection in 128 patients, including 14 using grafts. Complications associated with PV/SMV reconstruction and harvesting venous grafts and reconstructed PV/SMV patency during follow-up were assessed.

Results

Of the 128 patients, 5 underwent total pancreatectomy, 99 pancreaticoduodenectomy, and 24 distal pancreatectomy. In the 14 patients who underwent PV/SMV reconstruction with grafts, the grafts were harvested from the external iliac vein (EIV) in 10 patients and internal jugular vein (IJV) in the other 4. Five patients (3.9 %) had an intraoperative or postoperative acute thrombus or stenosis of reconstructed PV/SMV after direct end-to-end anastomosis. However, PV/SMV patency was excellent after reconstruction using grafts. There were no significant differences in other complications between groups with and without the use of grafts. Three patients (30 %) with EIV grafts had postoperative leg edema, and one of them required analgesics until his death because of leg pain caused by compartment syndrome, whereas no patients with IJV grafts had complications associated with sacrificing veins.

Conclusions

Depending on the length and/or position of the removed PV/SMV segment, interposed graft may be required for reconstruction in some patients, and the use of graft vein, particularly using IJV, is an appropriate procedure that is not associated with any complications.     

门静脉和肠系膜上静脉血栓形成的CT、MRI诊断

目的探讨门静脉（PV）和肠系膜上静脉（SMV）血栓形成的CT、MRI征象及其诊断价值。方法回顾性分析25例经手术与病理证实的PV-SMV血栓形成病例CT和MRI检查资料。结果PV-SMV血栓形成的直接征象CT表现为PV-SMV血管内充盈缺损,PV周围呈轨道样增强;MRI表现为PV和SMV正常流空信号消失;急性、亚急性期血栓T1WI呈等或高信号,T2WI呈高信号;GD-DTPA增强扫描静脉期PV-SMV管腔内对比剂充盈缺损。PV-SMV血栓形成的间接征象包括肠腔扩张积液,肠管积血,肠壁增厚,肠黏膜水肿,薄纸样肠壁,缆绳征,肠系膜积液,肠壁积气,腹腔积液,门静脉海绵样变,肝脏异常灌注。结论CT、MRI是诊断PV-SMV血栓形成最有效的影像检查方法,MRI对PV-SMV血栓形成的定位、定量及血栓的分期优于CT。     

Increased reduction in exsanguination rates leaves brain injury as the only major cause of death in blunt trauma

IntroductionCentral nervous system (CNS) related injuries and exsanguination have been the most common causes of death in trauma for decades. Despite improvements in haemorrhage control in recent years exsanguination is still a major cause of death. We conducted a prospective database study to investigate the current incidence of haemorrhage related mortality.Materials and methodsA prospective database study of all trauma patients admitted to an urban major trauma centre between January 2007 and December 2016 was conducted. All in-hospital trauma deaths were included. Cause of death was reviewed by a panel of trauma surgeons. Patients who were dead on arrival were excluded. Trends in demographics and outcome were analysed per year. Further, 2 time periods (2007–2012 and 2013–2016) were selected representing periods before and after implementation of haemostatic resuscitation and damage control procedures in our hospital to analyse cause of death into detail.Results11,553 trauma patients were admitted, 596 patients (5.2%) died. Mean age of deceased patients was 61 years and 61% were male. Mechanism of injury (MOI) was blunt in 98% of cases. Mean ISS was 28 with head injury the most predominant injury (mean AIS head 3.4). There was no statistically significant difference in sex and MOI over time. Even though deceased patients were older in 2016 compared to 2007 (67 vs. 46 years, p < 0.001), mortality was lower in later years (p = 0.02). CNS related injury was the main cause of death in the whole decade; 58% of patients died of CNS in 2007–2012 compared to 76% of patients in 2013–2016 (p = 0.001). In 2007–2012 9% died of exsanguination compared to 3% in 2013–2016 (p = 0.001).DiscussionIn this cohort in a major trauma centre death by exsanguination has decreased to 3% of trauma deaths. The proportion of traumatic brain injury has increased over time and has become the most common cause of death in blunt trauma. Besides on-going prevention of brain injury future studies should focus on treatment strategies preventing secondary damage of the brain once the injury has occurred     

门静脉节段切除治疗进展期胰腺癌

目的 研究侵犯门静脉（PV）的胰腺癌的切除方法及治疗效果。方法 对22例胰腺癌患者在施行胰十二指肠切除或胰体尾部切除时清扫区域淋巴结，并联合切除受侵犯的一段PV或肠系膜上静脉（SMV）。结果 行PV或SMV楔形切除修补者6例，节段切除者8例，其中5例行端端吻合，2例行自体大隐静脉移植，1例行肠系膜上静脉下腔静脉转流。平均手术时间7.，平均术中输血600ml，无围手术期死亡。22例患者全部得到随访，存活6个月1例，12个月3例，18个月6例，24个月8例，36个月4例。结信纸 侵犯PV和（或）SMV的胰腺癌切除加广泛淋巴清扫是安全可行的，且能延长患者的生存期。     

Extracorporeal life support is safe in trauma patients

IntroductionThe role of extracorporeal life support (ECLS) in the critically ill trauma patient is poorly defined, possibly leading to the underutilization of this lifesaving therapy in this population. This study examined survival rates and risk factors for death in trauma patients who received ECLS.MethodsData from the National Trauma Data Bank was retrospectively reviewed to identify trauma patients who received ECLS from January 2012 to December 2014. Clinical outcomes and risk factors for death were examined in these patients.ResultsEighty patients were identified and included in the final analysis. Overall survival to hospital discharge was 64%. Survivors and non-survivors were similar in regard to age, gender, weight, and injury mechanism. Non-survivors had greater median injury severity scores (ISS) (29 non-survivors vs. 24 survivors, p = 0.018) and had a shorter median total hospital length of stay (8 days non-survivors vs. 32 days survivors, p < 0.001). Analysis of specific anatomic locations of traumatic injury, including serious head/neck, thoracic, and abdominal injuries, revealed no impact on patient survival. Multivariable logistic regression analysis identified increasing age and ISS as significant risk factors for mortality; whereas treatment at facilities that performed multiple ECLS runs over the study period was associated with improved survival.ConclusionsExtracorporeal life support appears to be an effective treatment option in trauma patients with severe cardiopulmonary failure. Survival in trauma patients receiving ECLS is similar to that observed in the general ECLS population and this may represent an underutilized therapy in this population.     

Operative management and outcome of 302 abdominal vascular injuries

BACKGROUND: Abdominal vascular injuries incur high mortality rates. The purposes of this study are (1) review institutional experience, (2) determine additive effect on mortality of multiple vessel injuries, (3) determine mortality of combined arterial and venous injuries, and (4) correlate mortality with American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) for abdominal vascular injury. METHODS: A retrospective 6-year study was made at an urban level I trauma center of patients with abdominal vascular injuries. Main outcome measure was survival. RESULTS: (1) There was a total of 302 patients, mean age 28, mean Injury Severity Score (ISS) 25 (range 4 to 75). Mechanism of injury was penetrating in 266 (88%), blunt in 36 (12%). Emergency Department thoracotomy was done in 43 of 302 (14%), 504 vessels were injured: arteries 238(47%), veins 266(53%). Surgical management was ligation 245, primary repair 141, prosthetic interposition grafts 24, autogenous 2. Overall mortality was 162 of 302 (54%). (2) Mortality multiple vessels injured: 1 vessel 160 (45%), 2 vessels 102 (60%), 3 vessels 33 (73%), >4 vessels 5 (100%). Mortality arterial injuries: aorta isolated (I) 78% versus combined with other arterial injuries (C) 82.4%, superior mesenteric artery (SMA) I 47.6% versus C 71.4%, iliac I 53% versus C 72.7%, renal I 37.5% versus C 66.7%. Venous injuries: inferior vena cava (IVC) isolated (I) 70% versus combined with other venous injuries (C) 77.7%, superior mesenteric vein (SMV) I 52.7% versus C 65%, IMV I 16% versus C 50%. (3) Specific mortality combined arterial and venous injuries: aorta plus IVC 93%, SMA plus SMV 43%, iliac artery plus vein 45.5%. (4) Mortality versus AAST-OIS: grade II 25%, grade III 32%, grade IV 65%, grade V 88%. CONCLUSION: Abdominal vascular injuries are highly lethal. Multiple arterial and venous injuries increase mortality. Mortality correlates with AAST-OIS for abdominal vascular injury.     

Traumatic injuries of the portal vein. The role of acute ligation.

Injuries to the portal vein are rare but have a high risk with a mortality of 50--70% secondary to exsanguinating hemorrhage. When managing injuries to the portal vein, lateral venorrhaphy, end to end anastomosis, or an interposition graft should be attempted whenever possible. However, in a hemodynamically unstable patient or when confronted with a nonreconstructable injury, acute portal vein ligation may be the procedure of choice as it is safely tolerated in some 80% of patients. Of eleven reported patients in whom the portal vein was ligated acutely for traumatic injury, six survived. Four of the nonsurvivors died of massive associated injuries. Of the six surviving patients, five tolerated acute ligation of the portal vein without complication. Should portal vein ligation be performed a "second look" operation is essential in 24 hours to examine the bowel for viability. A portosystemic shunt with its inherent complications should not be done as a primary procedure when attempts at reconstruction of the portal vein have failed. Shunting should be reserved for those few patients who develop stigmata of portal hypertension or impending infarction of the bowel.     

Acute trauma of the femoral artery and vein.

Between 1974 and 1991, 233 patients were treated for 321 confirmed femoral vascular injuries. There were 112 patients (48%) with isolated arterial injuries, 36 (15%) with isolated venous injuries and 85 (36%) with combined arterial and venous injuries. Injury to the concomitant superficial or common vessels occurred in 27 (8.3%) and 9 (1.7%) patients, respectively. Associated extremity injuries included bone, 15%; soft tissue and muscle, 11%; and nerve, 7%. Sixty patients (26%) had fasciotomies. Arterial thrombosis occurred in five superficial repairs. Eighteen repaired veins thrombosed--eight of 61 simple (lateral venorrhaphy) and ten of 50 complex repairs. Thirty-four percent of patients with a repaired venous injury had clinical evidence of postoperative venous morbidity--deep vein thrombosis (DVT), edema, pulmonary embolus. Six patients (2.5%) had a documented pulmonary embolus--four in the 18 patients (22%) with clotted venous repairs. Eleven patients (4.7%) underwent an amputation. Five of the amputations were in patients with either inadequate or delayed fasciotomy. An inadequate fasciotomy was equally as deleterious as a delayed fasciotomy in terms of outcome. Six of 27 limbs (22%) with a femur fracture required an amputation. There were six deaths. Acute limb morbidity was related to the extent of associated limb trauma, i.e., soft-tissue, nerve, and bone damage. Chronic morbidity was related to neurologic deficits and venous sequelae. Vascular injury to the femoral vessels was associated with a high morbidity but low mortality.