LAUSR

Trauma is the third leading cause of avoidable death in the UK, and globally is responsible for 5.8 million deaths per annum. The incidence of vascular injuries in major trauma patients varies from 4.4% in civilian centres up to 15% in military conflicts in Iraq and Afghanistan. Vascular injuries are the sequelae of both blunt and penetrating trauma mechanisms, occur in truncal and peripheral body areas, and in vessels of any size. Arterial damage carries high mortality due to exsanguination and distal tissue ischaemia, with management strategies that are well documented. Venous injuries are less common: an observational study at one London Major Trauma Centre demonstrated 73 venous injuries over five years, half of which presented in association with arterial injury. Although a low flow system, left untreated, venous injuries carry shortand long-term morbidity, including reduced venous outflow, compartment syndrome, thromboembolism, venous hypertension and the associated post-thrombotic syndrome. In high volume veins, haemorrhage is often fatal: iliac, portal and mesenteric vein injuries have a mortality of 50–70%, and 30–50% of isolated inferior vena cava (IVC) injuries succumb in the pre-hospital setting. During the Second World War, peripheral vein ligation was favoured in both isolated venous injuries and in injuries involving the concomitant artery. Venous repair was not taken up until the Korean War, when evidence of reduced morbidity by maintaining venous outflow began to emerge. In current practice, repair of peripheral venous injuries is favoured over ligation, and pre-operative control of exsanguination from peripheral venous injuries is possible with external compression. Where repair is not possible, ligation is tolerated well. Truncal injuries are more difficult to access surgically and often involve larger or high flow veins. Patients suffering from truncal vein injuries often have associated thoraco-abdominal organ injuries, as well as a physiological response to trauma. Ligation of these veins can lead to major complications, and many of the surgical challenges associated with repair are also encountered in ligation. As such, the control of haemorrhage and subsequent repair of truncal veins remain the favoured approach, traditionally with thoracotomy or laparotomy. The evolution of endovascular surgery has transformed the management of vascular injuries. The use of endovascular technologies in arterial injury is widespread, and in many cases has surpassed open surgery: endovascular repair is now the de facto treatment for blunt thoracic aortic injuries. Venous stenting has been used to treat venous outflow obstruction since the 1990s, and venous stent placement under ultrasound or fluoroscopic guidance has a high success rate. A number of case reports describing successful venous stenting in trauma have been published. Six reports describe stenting of the IVC. Of these, two cases suffered isolated, iatrogenic injuries to the IVC whilst undergoing other surgical procedures, and the other four were trauma victims with other associated injuries. In all cases, off-the-shelf arterial stent grafts were used, including one fenestrated arterial graft in a juxta-hepatic IVC injury. Four cases of successful iliac (common and/or external) vein stenting have been reported, all in road traffic collision victims, as has one case of brachiocephalic vein stenting following iatrogenic injury, and one case of axillary vein stenting following penetrating trauma. All cases reported successful repair of the vein, maintenance of venous flow and discharge from hospital. No reports of stenting of peripheral veins were identified. Endovascular stenting offers a minimally invasive intervention with low physiological burden in cases of venous injury. This is particularly useful in polytrauma patients, who often have multiple severe injuries, and limited remaining physiological reserve.