The body is made up of several transport systems, including the arterial, venous, and lymphatic systems as well as the neurologic system. Injury to any of these systems may occur and, almost always, when an injury occurs to an area, it affects more than one system. Certainly, the venous system is subject to damage whenever an injury or traumatic experience occurs. The trauma may be minimal and therefore the injury may be minimal; however, the trauma may seem simple, and the injury may be severe but masked when no major outward signs are noted. Venous trauma may include injury to the endothelium, the venous musculature, or the adventitia of the vein. Such trauma may be compression (i.e., crushing) in nature as well as transectional (both partial and complete) and linear as well as cross-sectional. Each of these injury types may require a different therapeutic approach.

Trauma per se is a leading cause of death in both the civilian as well as the military arena. It is particularly noted in young individuals and most commonly is seen in accident-prone individuals such as little children, teenagers, and young adults learning and experimenting with different ways of life. The male population is more commonly involved. The frequency of significant venous injuries is much less than the frequency of arterial, musculoskeletal, or truncal injuries. This is partly because venous injuries are not of primary or major concern in most traumatic situations. Thus, in general, trauma, or vascular surgeons’ reporting of venous injuries is limited because the treatment of patients with such injuries may be limited. Most significant and reported venous injuries occur in association with other injuries such as arterial, truncal, orthopedic, or gastrointestinal (GI) injuries (Figures 33-1). Isolated examples of venous trauma remain infrequent and are seldom reported.

Table 33-1 lists the various types of venous trauma. As presented in the table, there are three main causes of significant venous injury. By far, the most common of these in the civilian population is the blunt injury in which a significant force may strike the abdomen, chest, head, or extremity (Figures 33-2 and 33-3). The injury may cause interruption, contusion, or compression of the venous structures. The swelling in association with the trauma may limit the diagnosis of a venous injury for some time or may totally obscure the injury when observation and time lapse allow healing. Penetrating injuries are frequently associated with perforation of other structures, which take priority in the treatment scheme. In certain communities, gunshot wounds and knife stabbings are more prevalent than in others.

During passage of these penetrating instruments, injuries to arteries, veins, the GI tract, kidneys, spinal cord, and head and neck structures may all occur. Concentration on these entities reduces the potential recognition of significant corresponding venous injury. When the patient requires surgical exploration to control and repair the various injuries, particularly in arterial and GI contamination situations, the physician may encounter transection or perforation of the associated venous structures. Bleeding from these injured structures may be profuse and difficult to control. Compression of the venous bleeder usually controls some or all of the bleeding. But simultaneous control of the vessel to reduce blood loss may be very difficult in acute situations in which arterial, venous, and other injuries have occurred and patient stability is an issue.

One of the causes of venous trauma that is often overlooked but is a frequent concern in busy operating suites is iatrogenic venous injuries. These injuries may occur in different circumstances and different types of surgical endeavors (Figures 33-4, 33-5, 33-6). The popliteal veins as well as iliac veins may be damaged during orthopedic surgery. The iliac veins and vena cava may be injured during arterial (e.g., aneurysm surgery) and major tumor resections, including nephrectomy. Other iatrogenic venous injuries involving the mesenteric or portal venous systems are known to occur during major tumor and pancreatic surgery and adhesion release and in patients with portal hypertension. Pelvic venous complications may result from pelvic exenteration and other gynecologic surgery. Difficult neck dissection may also be complicated by jugular venous concerns during extensive trauma surgery. It should be noted, however, that most venous injuries are associated with other concomitant major injuries as a result of blunt, penetrating, or iatrogenic causes. Severe thermal burns may also cause venous complications.

The causes of venous injuries are multiple and diffuse. The leading cause of venous blunt contusional as well as transectional injury appears to be motor vehicle accidents. These accidents may transect, lacerate, or contuse vessels in the leg; abdomen; or chest, including the pulmonary venous structures. Large hematoma and compressive injuries to various venous structures are all possible. Renal artery and vein lacerations or disruptions from motor vehicle accidents with motorcycles or automobiles certainly occur.¹ Penetrating injuries, including low- and high-velocity gunshot wounds from rifles, shotguns, and pistol injuries, stab wounds, or bone fragment puncture, all occur in the civilian population.

Certainly, firearm and explosive usage during wartime situations may be a major cause of venous penetrating injury. However, if one considers the high incidence of gunshot wounds in the civilian population of the United States from suicide, homicide, accidental causes, and police conflict, one can appreciate the potential for venous injuries. Depending on a physician’s hospital affiliation, one might see more blunt injuries from automobile accidents, falls, or work-related accidents than other hospitals located in areas of frequent gunshot wounds and stabbing situations. Civilian injuries are more commonly seen in the neighborhood community and are searched for under different circumstances than when miliary concerns are present. Terrorism and active combat lead to more penetrating injuries either from gunshot wounds or from explosive fragments such as roadside bombs, landmines, and other such explosive weapons.