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We reviewed the literature concerning arterial thromboses associated with the nephrotic syndrome and the hypercoagulable state. An illustrative case of peripheral arterial thrombosis and pulmonary emboli attributed to the hypercoagulable state of the nephrotic syndrome is included. In our patient, serum levels of antithrombin III, plasminogen, factor VII activity, factor VIII activity, and factor VIII antigen were abnormal. Arterial thromboses in patients with the nephrotic syndrome are often associated with steroid and diuretic use. In pediatric patients, a predisposing factor may be femoral venipuncture.

Two infants with five separate episodes of extravasation from hyperalimentation catheters are described. Three were intrathoracic and two were retroperitoneal, one of the latter producing clinical ascites. Clinical respiratory distress or ascites developing in an infant undergoing hyperalimentation may indicate vein wall perforation with extravasation into the pleural or abdominal cavities or the retroperitoneum. Questionable situations may be readily resolved by contrast injection through the catheter. Suboptimal position of the catheter tip and venous thrombosis seem to be major contributors to this problem. Prompt recognition and removal of the catheter are generally sufficient to correct the situation.

The aim of this study was to assess the long-term clinical and physiological sequelae of lower limb venous trauma in a civilian practice. Twenty-six patients who had undergone surgery for lower limb venous trauma (median elapsed time 19.5 months) underwent assessment. Injuries had been sustained to the external iliac, common femoral superficial femoral and popliteal veins in two, four, nine and eleven limbs respectively. Using clinical assessment, photoplethysmography recovery time, the presence of popliteal reflux and venographic evidence of thrombosis, the final outcome was graded as good, fair or poor. Fourteen patients had pedal oedema, including two with a postphlebitic limb. The overall photoplethysmography recovery time (mean and s.d.) was 20.6 (8.7) s in the injured and 32.1 (6.7) s in the non-injured limbs (P = 0.002). Patients with a venographically occluded vein had a shorter photoplethysmography recovery time than those in whom the vein was patent (13.4 (5.6) versus 21.6 (8.7) s; P = 0.07). Popliteal reflux was present in 12 injured limbs. Seven of 12 venograms performed on limbs with a vein repair had evidence of previous thrombosis. Vein ligation carried considerable morbidity and all end-to-end anastomoses initially failed. In retrospect, saphenous vein grafts were too narrow for the recipient veins and panel grafts might have been more appropriate. Overall 11 of 26 patients (42 per cent) had a poor result. The repair of choice is a saphenous vein patch for lesser injuries and a saphenous panel graft for major injuries. Vein ligation should be avoided unless another life-threatening injury demands priority.

Intravenous digital vascular imaging was used to evaluate eight patients with suspected iatrogenic femoral arteriovenous fistulae. These followed either cardiac catheterization (seven) or pulmonary angiography (one). All cardiac catheterization patients had undergone simultaneous ipsilateral femoral artery and vein puncture, possibly contributing to the high incidence of arteriovenous fistulae in this group. Digital imaging studies in two patients were normal, confirmed by clinical follow-up without surgery. In six patients, digital vascular imaging correctly predicted the presence and relative size of the fistulae, as confirmed at surgery. Although the exact site could not be specified, it was correctly identified to within 4 cm. None of these patients required arteriography for further study of the lesion before surgical repair.

The treatment of venous injuries remains controversial. In an attempt to evaluate the results of current management of venous injuries, we retrospectively reviewed our experience between 1979 and 1984. During this period 142 patients had sustained injuries to 158 veins in the neck (31 patients), abdomen (45 patients), upper extremity (20 patients), and lower extremity (62 patients). Overall, 90 venous injuries (61%) were repaired, including 83% of caval and iliac vein injuries and 90% of injuries to the common femoral, superficial femoral, and popliteal veins. There was no morbidity after repair of 73 major veins. Morbidity occurred in four of 11 patients after ligation of major veins (edema in two patients and above-knee amputation in two others). Both ligation (N = 51) and repair (N = 17) of lesser veins (jugular, brachial, profunda femoral, tibial, and minor abdominal veins) resulted in no morbidity. Overall mortality was 6% with all deaths occurring in patients with abdominal venous trauma. These data indicate that repair of venous injuries can be performed without morbidity and that minor veins can be ligated without adverse sequelae. However, in view of the morbidity associated with ligation of major veins, efforts to restore flow to these injured vessels appear appropriate unless contraindicated by life-threatening injury.

Over a 10-year-period extending from January 1976 to September 1986, 800 peripheral vascular injuries were surgically treated at the American University of Beirut Medical Centre. Of these, 150 were operated on because of injury to the femoral vessels. Bullets were the commonest wounding agents (60% of cases). Thirty-seven patients had a femoral artery injury, 27 a femoral vein injury and 86 combined femoral artery and vein damage. Twenty-three per cent of the patients had an associated fracture of the femur. Patients with fractures had an 11% amputation rate compared with 1% for those without fractures. Our data reveals the importance of venous reconstruction in the presence of an arterial injury instead of its ligation (P less than 0.05), particularly when there is an associated fracture of the femur. Thirty-seven per cent of patients were in shock on admission (systolic BP 90 mmHg). The amputation rate in these patients was 6.8% in contrast to 1% in the haemodynamically stable group (P less than 0.05). The overall amputation rate was 3.3%. Complications occurred in 36.6% of patients and the mortality was 4.0%.

Reimplantation after subtotal section of the right lower limb under the Scarpa triangle was been attempted and was successful. Section and contusion of the femoral artery and vein required 2 end-to-end saphenous bypass grafts. The use of the lower limb is correct, after to a follow up of 4 years. The risks, inherent to all proximal section, with important muscular masses, in a small child, are described. Functional prognosis depends on three aspects: bone, vessels, and nerves. A tibial pseudarthrosis had to be operated secondarily with significant lengthening. A partial stenosis of the graft was demonstrated arteriographically. Pes equinus, a result of paralysis, has been fitted with an orthesis. This observation is almost an experimental one: what can be the future of a reimplanted lower limb in the child.

The difficulties met, when reconstructing an injured v. femoralis communis, are greater than those of other veinous segments of the leg. This is due to the fact that the vein, being disconnected from its natural braces, is compressed by the inguinal ligament. In order to overcome this elective difficulty, a modification of the ring of Kunlin, especially thought out for this part of the body and clinically tested, is presented.

One hundred and eleven traumatic anterior dislocations of the hip in children were collected from the literature and statistically evaluated together with 4 cases treated at our institute. The incidence of open dislocations, associated lesions (avulsion of the greater trochanter, damage to the femoral vessels, and fracture on the shaft of the ipsilateral femur), and irreducible recent dislocations was noteworthy, demanding special methods of primary management. In 41 patients, with follow-up averaging 5 years, the incidence of complications, especially avascular necrosis, was also high. Anterior dislocation of the hip in this age group is to be considered a serious injury. Concerning the final state of the hip-joint, factors giving a poor prognosis appear to be severe injury, open dislocation, associated fractures near the joint, delayed reduction, and, possibly, open procedures.

Thirty-two patients were operated upon for suspected vascular injury following penetrating wounds of the groin. This injury is not uncommon, the patients survive to reach the hospital, and they require aggressive management. Vascular damage was found in 23 of the patients; there were no deaths and only one amputation. Eighteen of the 23 who had vessel injury were in shock upon arrival at the hospital. Of those subsequently found to have no vessel damage, none was in shock. Pulses distal to the injury were noted in six of the 23 patients. Arteriograms performed and interpreted by the surgery residents were helpful but not completely reliable. The repaired vessel must be covered adequately with viable tissue. The one amputation was in a patient in whom there was insufficient tissue to cover the repaired vessel. We conclude that general surgeons should be capable of managing this vascular injury.

A road accident victim was admitted in shock with an injured lower limb virtually dismembered at mid-thigh level. The early use of intraluminal shunts bridging both femoral artery and vein permitted an unhurried but logical sequence of wound debridement, bone stabilisation and optimal vascular repair rendering fasciotomy unnecessary. This approach led to an uncomplicated survival of the limb with eventual return of function.

The pattern of operation injuries of the arterial vessels which may occur during hip surgery is illustrated by this summary of our own cases. Injuries of the femoral vessels seem to be preventable if the Hohmann-retractor is carefully placed on the anterior margin of the acetabular rim under digital control. Furthermore drilling damage of the iliac vessel appears to be avoidable. However, the replacement manoeuvre of the artificial acetabulum can be associated with massive bleeding despite greatest care. Under these circumstances immediate surgical intervention through an inguinal retroperitoneal approach is mandatory.

In two patients with femoral arterio-venous fistulae angiography could show arterial and venous collaterals with differing circulation phases. When angiography shows retrograde flow in the artery distal to the fistula, the volume of arterial collateral circulation is unrelated to the peripheral blood-supply. Venous collateral circulation has to be included in the fistular circulation. Angiography permits distinguishing a venous by-pass circulation for the return of blood from the periphery. In one patient a large aneurysm of the iliac vein was found. Special features of angiography, particularly after surgical closure of the fistula, are mentioned.

Our experience with 69 vascular injuries in 56 patients led us to modify the management of vascular injuries to the leg. We believe that prompt and complete angiography whenever the general condition of the patient allows it, early fasciotomy when indicated before vascular repair, thrombectomy of the injured artery and vein and local instillation of heparinized saline solution, vascular repair before orthopedic stabilization of fractures in selected cases, external fixation of the fracture when there is significant soft tissue injury, and early skin grafting resulted in an improved level of care with a low morbidity and no mortality in our series.

The effects of total hip replacement on the condition of the luminal surface of the jugular and femoral veins and the carotid and femoral arteries were studied in healthy dogs. Four hours after the completion of surgery, most of the blood was removed by whole-body perfusion and the vessels were partially fixed in situ by glutaraldehyde perfusion, harvested, and prepared for scanning electron microscopy. In control dogs (held under anesthesia) the luminal surfaces of the veins (including valves and confluences) and arteries were covered by intact endothelium and were free of adhering blood cells. The arteries from dogs that were operated on were also free of damage. In contrast, the veins from dogs that were operated on showed a series of roughly parallel microtears around 70 to 80 per cent of the confluences of the side branches with the jugular or femoral vein. The basement membrane as well as the endothelial sheet was torn, thereby exposing underlying connective-tissue fibers and smooth muscle cells. The endothelium separated along intercellular junctions. The tears were infiltrated with many leukocytes and platelets and some erythrocytes. Subtle endothelial changes and patchy leukocyte adhesion occurred away from the side branches. The mechanism or mechanisms remain to be elucidated.

1) Acute common femoral arterial injuries remain relatively uncommon in both military and civilian practice. 2) The recent experience in Vietnam has provided the most complete statistics regarding this type of injury. Among 1,000 acute major arterial injuries, the incidence of common femoral arterial trauma was approximately 5%. This present study reports 109 acute common femoral arterial injuries. Nearly two thirds of the injuries were caused by fragments and slightly more than one half of the injuries were lacerations. It was possible to perform autogenous vein graft repairs in about 57%, end-to-end anastomoses in about 25%, and lateral suture repair in about 10% of the injuries. Prosthetic material was used in only three repairs. 3) The overall complication rate was 28.3%, the amputation rate was 13.2%, and the mortality rate was 2.8%. 4) In the treatment of iatrogenic injuries associated with diagnostic catheterizations of the common femoral artery at Walter Reed Army Medical Center, there were no complications and no mortalities.

Some problems of surgical treatment of wounds of the proximal portions of the femoral vein are discussed. Considering the development of chronic venous insufficiency, resulting from the ligation of the vein at this level, the necessity of a timely restoration of the main blood flow in such vascular injuries is noted.

Indications for venous reconstruction after traumatic injury are controversial, partly because of uncertainty of continued patency. We found no reports in the literature of truly long-term results after venous reconstruction. For clarification of this issue, we reviewed femoral venous injuries in a civilian metropolital population over a 20-year period. There were 31 patients with penetrating femoral venous injuries. Twenty-four patients underwent reconstruction. A search for these patients years after reconstruction located only five patients with six reconstructions. Followup venography at 6 to 20 years demonstrated venous patency and functional valves with asymptomatic patients and no clinical evidence of venous insufficiency in all cases excluding a single 1962 repair with a Teflon graft. This study then supports reconstruction rather than ligation after venous trauma. Although small, this series appears to be the only known report of truly long-term results following venous reconstruction.

Femoral vein injury in a newborn infant after cardiac catheterization resulted in a threat of limb loss because of a compartment syndrome. The limb was saved by full-length medial and lateral skin and fascial incisions.

Closed reduction of an anterior dislocation of the hip joint in a 15-year-old boy failed because of interposition of capsule, iliopsoas and rectus femoris muscles. The immediate complications were compression of the common femoral artery, tear of the femoral vein, and fat embolism 24 hours after the injury. The sequelae were periarticular ossification and avascular necrosis of the femoral head. The definitive treatment was a Charnley total hip arthroplasty.

A patient is reported with successful clinical recanalization of a thrombosed saphenous vein interposition graft in the superficial femoral vein after civilian injury. Primary repair of venous injuries may prevent both initial acute venous hypertension as well as the development of chronic venous insufficiency.

The records of 50 patients with 67 major civilian type vascular injuries treated in a large urban center from 1967 to 1975 were reviewed in terms of nature of the injury, form of surgical management and early and late results. Civilian injuries differ in many aspects from those of their military counterparts and often require different treatment. In both, however, treatment protocols should be periodically re-evaluated for a number of reasons, chiefly among which are changing patterns of delivery of the injured patient to the medical center and advances in technical skills. Notable in the presently reported series were the low mortality and the absence of a need for amputation, with a limb salvage rate of 100 per cent. Despite modern advances in technical proficiency in vascular reconstruction, there is still a place for careful vascular ligation in the definitive surgical management of major vascular trauma.

An important complication of temporary cardiac pacing by the transfemoral approach. This report describes three cases of inapparent double puncture of the femoral artery and vein as a complication of the transfemoral approach for temporary cardiac pacing. This complication may lead to the passage of a pacing catheter to the right ventricle by way of the femoral artery and vein and may remain undiagnosed until the rigid outer sheath of the introducer set is withdrawn over the pacing catheter. Therefore, we recommend immediate withdrawal of the rigid outer sheath as soon as the catheter lies freely in the iliac vein or the inferior vena cava. If double puncture has occurred, arterial blood will leak around the pacing catheter. Control of arterial bleeding by local compression should not be attempted without removal of the pacing catheter.

Venography is a simple and rapid technique which can be used in the diagnosis of acute penetrating venous injury. Four cases of venous lesions are presented and indications for venography discussed. Findings consisted of bleeding from lacerations and partial or total occlusion from traumatic thrombosis.

During a 4 year period (1979 through 1983), 181 major arterial (69 percent) and 81 venous (31 percent) injuries were treated surgically. Of the venous injuries, 24 (30 percent) involved the femoral veins (9 common femoral, 15 superficial femoral). Management of these femoral venous injuries included lateral venorrhaphy in 10 cases (42 percent), venous patch angioplasty in 5 cases (21 percent), end-to-end anastomosis in 4 cases (17 percent), interposition autogenous saphenous vein grafts in 3 patients (12 percent), and ligation in 2 cases (8 percent). One case that included common femoral venous ligation and one that included a failed interposition saphenous vein graft in the superficial femoral vein subsequently were managed with in situ saphenous vein bypass. For one interposition saphenous vein graft repair of the common femoral vein we utilized the spiral vein graft technique. Excluding one early death from associated injuries and one superficial femoral venous injury managed by ligation without postoperative complications, 17 of 23 (74 percent) femoral venous repairs were judged patent postoperatively (13 confirmed by venography and 4 by noninvasive testing). The adjuvant use of intermittent pneumatic calf compression and low molecular weight dextran appears to have been beneficial in maintaining patency of the femoral venous repairs. Early clinical follow-up demonstrated the presence of edema in 6 of 8 cases (75 percent) initially treated by ligation or complicated by postoperative occlusion. Early postoperative edema, present in 4 of 17 (24 percent) patients with patent venous repairs, had resolved by the time of discharge. We recommend routine repair of femoral venous injuries. When significant edema or ischemia develop following obligatory venous ligation or postoperative occlusion of a venous repair, revision or venous bypass should be considered.

Simple ligation of major venous injury can be both limb threatening and create chronic disability (9). A case of penetrating trauma to the thigh producing isolated major venous injury is presented. An aggressive approach, immediate exploration, and lateral suture and non-reversed saphenous vein graft, are advocated for the diagnosis and treatment of venous trauma.