Analysis of Concomitant and Isolated Venous Injury in Military Lower Extremity Trauma

Published:April 19, 2022DOI:


      The implications of major venous injury to the lower extremity are not well established. We aimed to determine the significance of concomitant and isolated femoropopliteal venous injury and assess the impact of surgical management strategies on limb outcomes.


      The Fasciotomy and Vascular Injury Outcomes database was queried for limbs sustaining femoropopliteal arterial, venous, or concomitant injuries in Iraq or Afghanistan between 2004 and 2012. Demographics, injury patterns and severity, interventions, and outcomes were compared between patients sustaining isolated arterial injuries (IAIs) and concomitant arteriovenous injuries (AVIs). In limbs with any venous injury, outcomes were compared between those undergoing venous repair and venous ligation.


      Three hundred thirty patients (133 IAIs, 135 AVIs, 62 isolated venous injuries [IVIs]) were included. AVI was associated with greater limb injury severity: median extremity Abbreviated Injury Scale (AVI 4 vs. IAI 3, P = 0.01), Mangled Extremity Severity Score >7 (25.9% vs. 13.5%, P = 0.01), and multilevel vascular injury (6.7% vs. 0.8%, P = 0.01) and with greater fasciotomy use (83.0% vs. 69.2%, P = 0.01). No differences were present in tourniquet use/time, shunting, or nature of arterial repair. No differences in vascular or limb complications (71.1% vs. 63.9%, P = 0.21) or amputation rate (25.9% vs. 18.8%, P = 0.16) were present, though the limb deep venous thrombosis rate was 12.6% in AVIs versus 7.5% in IAIs (P = 0.17). Limbs with IVI had a 12.9% amputation and a 74.2% complication rate. Repair (n = 103) versus ligation (n = 94) of venous injuries was not associated with a difference in amputation (18.4% vs. 25.5%, P = 0.23) or limb complication rates (71.8% vs. 72.3%, P = 0.94).


      Despite higher extremity injury severity and more frequent fasciotomies, concomitant venous injury was not associated with poorer limb salvage or complications. With nontrivial amputation and complication rates, IVI is indicative of severe limb trauma. Repair of femoropopliteal venous injuries does not appear to influence limb outcomes.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Annals of Vascular Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • White J.M.
        • Stannard A.
        • Burkhardt G.E.
        • et al.
        The epidemiology of vascular injury in the wars in Iraq and Afghanistan.
        Ann Surg. 2011; 253: 1184-1189
        • Patel J.A.
        • White J.M.
        • White P.W.
        • et al.
        A contemporary, 7-year analysis of vascular injury from the war in Afghanistan.
        J Vasc Surg. 2018; 68: 1872-1879
        • Grigorian A.
        Humerus fracture and combined venous injury increases limb loss in axillary or subclavian artery injury.
        Vascular. 2019; 27: 252-259
        • Ratnayake A.S.
        • Samarasinghe B.
        • Bala M.
        Challenges encountered and lessons learnt from venous injuries at Sri Lankan combat theatres.
        J R Army Med Corps. 2017; 163: 135-139
        • Feliciano D.V.
        • Kochuba M.P.
        • Rozycki G.F.
        Review article: history of venous trauma.
        J Trauma Acute Care Surg. 2021; 91: e62-e72
        • Williams T.K.
        • Clouse W.D.
        Current concepts in repair of extremity venous injury.
        J Vasc Surg Venous Lymphat Disord. 2016; 4: 238-247
        • Matsumoto S.
        • Jung K.
        • Smith A.
        • et al.
        Outcomes comparison between ligation and repair after major lower extremity venous injury.
        Ann Vasc Surg. 2019; 54: 152-160
        • Kochuba M.
        • Rozycki G.F.
        • Feliciano D.
        Outcome after ligation of major veins for trauma.
        J Trauma Acute Care Surg. 2021; 90: e40-e49
        • Kauvar D.S.
        • Staudt A.M.
        • Arthurs Z.M.
        • et al.
        Early fasciotomy and limb salvage and complications in military lower extremity vascular injury.
        J Surg Res. 2021; 260: 409-418
        • Byerly S.
        • Cheng V.
        • Plotkin A.
        • et al.
        Impact of ligation versus repair of isolated popliteal vein injuries on in-hospital outcomes in trauma patients.
        J Vasc Surg Venous Lymphat Disord. 2020; 8: 437-444
        • Frank B.
        • Maher Z.
        • Hazelton J.P.
        • et al.
        Venous thromboembolism after major venous injuries: competing priorities.
        J Trauma Acute Care Surg. 2017; 83: 1095-1101
        • Ratnasekera A.
        • Pulido O.
        • Durgin S.
        • et al.
        Venous thromboembolism after penetrating femoral and popliteal artery injuries: an opportunity for increased prevention.
        Trauma Surg Acute Care Open. 2020; 5: e000468
        • Farrell M.S.
        • Knudson M.M.
        • Stein D.M.
        Venous ligation versus venous repair: does the procedure impact venous thromboembolism risk?.
        Trauma Surg Acute Care Open. 2021; 6: e000687
        • Manley N.R.
        • Magnotti L.J.
        • Fabian T.C.
        • et al.
        Impact of venorrhaphy and vein ligation in isolated lower-extremity venous injuries on venous thromboembolism and edema.
        J Trauma Acute Care Surg. 2018; 84: 325-329
        • Manley N.R.
        • Magnotti L.J.
        • Fabian T.C.
        • et al.
        Factors contributing to morbidity after combined arterial and venous lower extremity trauma.
        Am Surg. 2018; 84: 1217-1222
        • Guice J.L.
        • Gifford S.M.
        • Hata K.
        • et al.
        Analysis of limb outcomes by management of concomitant vein injury in military popliteal artery trauma.
        Ann Vasc Surg. 2020; 62: 51-56
        • Kurtoglu M.
        • Yanar H.
        • Taviloglu K.
        • et al.
        Serious lower extremity venous injury management with ligation: prospective overview of 63 patients.
        Am Surg. 2007; 73: 1039-1043
        • Smith L.M.
        • Block E.F.
        • Buechter K.J.
        • et al.
        The natural history of extremity venous repair performed for trauma.
        Am Surg. 1999; 65: 116-120