Analysis of Limb Outcomes by Management of Concomitant Vein Injury in Military Popliteal Artery Trauma

Background: Despite aggressive limb salvage attempts, military popliteal artery injuries are associated with high amputation rates. Combined arterial and venous injuries present a management dilemma for military surgeons in austere settings, and the impact of vein injury management strategy on limb outcomes is not clear. Methods: Military casualties sustaining combined ipsilateral popliteal artery and vein injuries from 2003 to 2016 were identified from a military vascular injury database. Limbs were grouped based on whether venous ligation or repair was initially performed. The primary outcome was secondary amputation; the secondary outcomes included limb and vascular/graft complications. Results: Fifty-six limbs were included; of which, 27 (48%) were managed with vein ligation and 29 (52%) with repair. Veins were repaired primarily in 13 (45%) cases with the remainder being treated with interposition grafts. Median injury severity score was higher in the ligation group (19 vs 15, P = 0.09), but vascular and concomitant limb injury characteristics were similar. Amputation rates did not differ by vein treatment (45% repair vs. 41% ligation, P = 0.76), and this held with injuries above and below the knee considered independently. Most (71%) amputations were performed <30 days from injury. Amputation was indicated more frequently for vascular repair failure in the ligated group (55% vs 15%, P = 0.04). Four graft infections were all in the repair group (P = 0.07 vs ligation). Arterial graft complications were more frequent with vein repair (45%) than ligation (30%), but this did not reach significance (P = 0.24). Only one deep vein thrombosis was diagnosed in each group (P = 0.96). Conclusions: Type of management of concomitant popliteal vein injury was not associated with early or late amputation in this series of military popliteal artery injuries. Vein injury management may have had implications for the development of arterial graft and limb complications, however. Surgical decision-making regarding popliteal vein treatment should balance short-term contingencies with long-term limb salvage issues.