Iatrogenic venous injuries (IVIs).

The limb was revascularized 3 h after the injury. The postoperative course was normal. Post-surgical CK value was normal (145 Uyl). The patient was discharged on the 12th postoperative day and an anticoagulant therapy with warfarin sodium and compression stocking was started. At one-year follow-up, by means of duplex scan examination the artery and the vein were patent. No muscle or nerve impairment or leg edema was detected. Arterial and venous complications following varicose veins surgery are rare but devastating either for morbidity and mortality or for medico-legal implications w1x. The largest observational studies reported an incidence of major arterial and venous vascular complication ranging between 0.01–0.06% w2, 3x. These complications seem to be very anecdotal, but the review performed by Rudstrom et al. showing a total of 44 cases of arterial injuries with a high amputation and morbidity rate and another of 43 cases of venous injuries containing a severe morbidity with five fatal injuries w4x. Prompt diagnosis is mandatory to achieve a good outcome, but more than 30–60% of arterial injuries present as a late diagnosis due to postsurgical pain and bandaging causing a mistake and delay in diagnosis w5x. In our opinion, despite the extensive use of duplex scan examination in vascular practice, preoperative angiography should be the preference in all cases of postoperative late ischemia to achieve information about lesion extensions, profunda femoral artery and runoff status. The mechanism of injury is either direct trauma or inadvertent stripping of the artery and vein w6x. In the first case, a blind hemostasis seems to be advocated. Some anatomical conditions can predispose to vascular injuries. Young and slim women, with little subcutaneous tissue present with a small and bluish artery mimicking the saphenous vein. Some anatomical anomalies, like separate femoral entrance of the great saphenous vein below its tributaries, femoral artery and vein transposition or superficial femoral artery running in front of the saphenous junction seem to predispose to arterial injuries w7x. After an adequate dissection of the vascular structure, a debridement of the injured segment is performed to remove any area of contusion, sub-intimal hematoma and intima fracture can predispose to postoperative thrombosis. Primary repair with end-to-end anastomosis or short inter-position graft is usually performed. The contralateral great saphenous vein is the conduit of choice but in cases of the saphenous vein not being suitable for an extensive involvement in varicose disease, the use of arm veins …