According to statistics from the Great Patriotic War, the frequency of isolated damage to veins in medical institutions of the military and army regions was observed in 2,5-3,2% of cases. Much more often, injuries of the main veins were found in combination with damage to the artery of the same name, which accounted for 64,5% of the total number of vascular injuries with separation of the limb and 47,1% of cases without separation of the limb.
Under the conditions of the current local military conflict in the North Caucasus, the frequency of isolated damage to the main veins was noted in 23,1% of the wounded. Combined damage to the main arteries and veins was observed in 53,8%, with damage to long tubular bones – in 42,3% and with damage to large nerve trunks – in 19,2% of cases. Localization was dominated by damage to the main veins of the lower extremities (80,8%), and the most common injuries of the veins of the lower leg (38,5%).
Damage to small veins often proceed without complications and are often not diagnosed. In case of injuries of large venous trunks of the limbs, pelvis, chest, and neck, complications such as severe bleeding, up to the death from acute blood loss, air embolism, or the formation of a large paravasal hematoma can occur already on the battlefield.
The clinical picture of injury to the main veins depends on the type of damaged vessel, the duration of the injury, the presence of combined injuries and a number of other factors. Often with isolated wounding of the veins and compression of their surrounding tissues, bleeding is absent. In such cases, the victim or the person accompanying him can tell about the fact of severe bleeding.
Signs of damage to the veins: heavy bleeding, hematoma in the vessel, the location of the wound in the projection of the vein, swelling of the peripheral saphenous veins, cyanosis of the skin and swelling of the limb. In most cases, hematomas with closed damage to the veins due to the pressure of the surrounding tissues do not reach large sizes, are diffuse, do not have clear boundaries, are less stressed than arterial, and do not pulsate.
For a temporary stop of venous bleeding, it is enough to apply a pressure bandage and an elevated position of the limb. Rarely, with a large vein wound and severe bleeding, a tourniquet has to be applied. The final stop of bleeding is made depending on the location and nature of the damaged vessel.
The integrity of a large main vein, if the state of the wounded and the medical and tactical situation allows, should be restored by applying a lateral or circular suture or appropriate vein plastic. A large vein defect is restored by autologous prosthetics. The best donor material is a large saphenous vein taken from a healthy limb.
Ligation of large major veins, which can lead to a sharp violation of venous circulation in the limbs, is a necessary measure at the present stage of development of angiosurgery. Ligation of the following veins is practically not accompanied by impaired venous circulation: the femoral vein is distal to the discharge of the deep vein of the femur, the deep vein of the femur with preserved patency of the superficial and common femoral veins, one of the bundles of the leg veins (while maintaining the rest), large and small saphenous veins, radial and ulnar veins, one of the brachial veins with preserved patency of the second.
The treatment of gunshot wounds and closed injuries of the great vessels is a difficult task not only for military field surgery, but also for organizing the provision of emergency angiosurgical care in peacetime. In assisting the wounded with vascular damage, the time factor (the timing of the restoration of blood flow in the damaged vessel) is crucial.
At the XI International Conference of the Russian Society of Angiologists and Vascular Surgeons (Moscow-Krasnogorsk, 1997), a resolution was adopted on the treatment of wounds and injuries of the great vessels.
1. Modern gunshot wounds of arteries are extremely complex and are combined with extensive destruction of tissues with damage to bones (42,3%), large nerve trunks (19,2%) and major veins (53,8%). Such injuries are accompanied by shock in 90% of the victims, which requires timely and adequate resuscitation: effective temporary stopping of bleeding, infusion-transfusion therapy, stabilization of hemodynamics.
2. At the stages of qualified and specialized care, a full-fledged surgical treatment should be performed with the restoration of destroyed anatomical formations. First of all, the main blood flow should be restored by applying a vascular suture or autovenous plasty. The use of prostheses is permissible in extreme cases. If technical difficulties arise, the restoration of nerve trunks can be carried out in a later period.
3. It is necessary to strive for the restoration of the damaged artery in terms not exceeding 6 hours after injury. At the same time, the damaged trunk vein should be repaired. In case of limb ischemia over 6 hours, the plastic of arteries and veins should end with fasciotomy of all cases of the limb. Wounds should be drained with double-lumen tubes. In case of fractures, it is advisable to perform external fixation of bone fragments.
4. The use of temporary shunting of damaged arteries and veins is determined by the nature of the damage, the presence of conditions for performing reconstructive surgery, and the medical and tactical situation.
Recognizing the benefits of reconstructive surgery over ligature did not completely solve the problem of treating the wounded with vascular damage. Mortality (9,8%) and amputation of limbs (20-25%) remain quite high. Improving the technique of reconstructive operations, using new methods to maintain limb viability in severe ischemia, a well-organized organization and continuity in assisting the wounded are indispensable conditions for improving treatment outcomes.
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