PERIPHERAL CIRCULATION IN RELATION

TO TRAUMA*

WITH SPECIAL REFERENCE TO THROMBOSIS AND EMBOLISM

ARTHUR W. ALLEN, M.D.

Chief of the East Surgical Service, Massachusetts Genera1 Hospital; Lecturer in Surgery, IIarvard MedicaI School

BOSTON, MASSACHUSETTS

W HEN I was first approached on the subject of periphera1 circuIation in relationship to injury, I had in mind that I was supposed to deaI with injured bIood vesseIs-the

effect of heaIing of tissues dista1 to such Iesions, etc. I have been informed, however, that Dr. MarbIe’s idea was to have me discuss the question of thrombosis and embolism, which had interested us in this HospitaI so much during the past year. I very much regret that one of your members, Dr. Henry H. Faxon, is not here to present this phase of the subject since he’ and Dr. CIaude E. WeIch and Dr. C. E. McGahey have made a specia1 study of this situation and have sent in for pubIication an exceIIent articIe on the subject. Since a11 of these men are now with the MiIitary Forces, I will endeavor to give you a ritsume of our experience in this fieId.

Although thrombosis folIowed by embolism is not as common in the average patient who suffers an injury, as it is folIowing many major surgical procedures, there are instances that make us realize that one must be on the alert for this possibility in a11 patients regardless of their type of illness or injury. For some time, it has been the policy of our X-ray Department to interpret certain signs in the chest as due to infarct with great accuracy. In addition to this, the Pathologica Department have demonstrated that almost all fata pulmonary emboli, which we have encountered, have originated in the region of the popIitea1 vein. When such a thrombus propagates in both directions, the long column of the femora1 vein can produce an enormous cIot and one that, when it breaks Ioose in its entirety, wiI1 very often completely occIude the pulmonary artery.

SeveraI years ago, Dr. John Homans of Boston read a paper before the New EngIand SurgicaI Society advocating the Iigation and division of the femora1 or the iliac vein, foIIowing repeated sub-

* From the Surgical Service of the Massachusetts General Hospital.

I77

ALLEN-CIRCULATION AND TRAUhlA

letha infarcts in patients who had a Iow-grade inflammatory or mechanica condition in the vein producing thrombosis. AIthough this was an interesting observation that Dr. Homans reported, three or four cases at that time, beIieving that he had perhaps prevented fatal emboIus under these circumstances, I doubt if there was any

widespread attention paid to this suggestion. ActualIy, it was two or three years afterward before I found a case that I thought fitted into his group and on whom I was wiIIing to do a high Iigation. GraduaIIy, there has come about a much more radical attitude about the entire situation.

First of aI1, one must get over the feeIing that interruption of the femora1 or even the iIiac vein wiI1 produce severe invalidism. There occurs some swelling in the extre’mity after ligation but this is not disabIing; it Iasts for varying periods of time, but rarely handicaps the patient in his usua1 routine of Iife. The disabiIity, in fact, is so sIight that our internist coIIeagues believe that it is entireIy minor as compared with the risk of waiting to see whether the patient wouId deveIop a more massive emboIus. It only takes an instance or two in a man’s experience of fatal emboIus in an otherwise heaIthy patient to make him fee1 considerabIy more radica1 about this whoIe

matter. FataI puImonary emboIus occurred in this Hospital prior to

Dr. LincoIn Davis’ study3 of fifteen years ago at the rate of three deaths in every thousand patients who had been subjected to a major surgica1 operation.

After this, various methods of prevention of phIebitis were in- stituted, such as eIevation of the foot of the bed, bicycIe exercises

of the Iegs, frequent turnings, etc. These methods, with perhaps better attention to the handling of tissue, the eIimination of pres- sure bandages over Iarge vesseIs, have (according to a recent study by Drs. WeIch and Faxon on patients in this same Institution) reduced the number of fata emboIi to about one in a thousand operations.

At first, it seems as though we might be able to pick up the earIy signs of phIebothrombosis or thrombophIebitis by a routine, bi- daily, carefu1 inspection of the extremities of these postoperative cases. This is done by the resident staff reIigiousIy and frequentIy enough earIy signs can be noted, aIthough these may be minimaI. It is not at a11 uncommon now to have these signs picked up before the patient is aware of any disturbance or before the chart indicates that there is this compIication impending. These examinations con-

ALLEN-CIRCULATION AND TRAUMA I79

sist in an observation of the extremities, both being uncovered; the question of whether the superficial veins are fiIIed or empty; whether there is any sweIling by actual measurements; whether there is any tenderness in the calf of the leg, and whether or not there is a positive Homans’ sign.

This last sign is by far and above the most helpful of all and is determined by the following method : With the patient’s leg in exten- sion, the palm of the left hand is placed gently on the patella; the right hand grasps the distal segment of the foot, which is gentIy but

forcibly dorsiffexed. If during this maneuver, the patient is per- fectly comfortabIe, one can feel reasonabIy assured that the veins in the poplitea1 space are not invoIved in any pathoIogica1 process. If, on the other hand, the patient complains of discomfort in the caIf of the leg or in the popliteal space when this maneuver is done, one can then be reasonably sure that future developments will reveal a thrombosis in the vein. We do pay considerable attention to superficia1 phIebitis when it develops and believe that, when it is discovered, ligation at the foramen ovale of the long saphenous vein is indicated. This, we believe, has perhaps prevented a good many

instances of deep phIebitis and has made it possible to shorten the convalescence of these patients tremendousIy.

Although we see a number of cases that certaimy fail into the group which Dr. Alton Ochsnerj has caIIed phlebothrombosis, we have here in this community a larger number of true inflammatory thromboses of the vein than they seem to have in New OrIeans. It is probably due to the fact that we have more lowered resistance due to our climate, etc., than they find in the deep South. It is a well known fact that we have more postoperative pulmonary complica- tions in this region than they have in warmer areas. This we beIieve is

due to the same difference in chmactic conditions. In the recent study, it was found that 93 per cent of all of the

fatal emboli occurred in peopIe who had absoIutely no sign whatever of a previous thrombosis. They had not complained of any discom- fort in their Iegs, they had no change in p&e, temperature, or respiration, and undoubtedly most of these should be cIassified as phIebothromboses. In these patients, the pathologist invariably found the origin of the emboIus to be in the deep veins of the leg.

Further analysis showed that in the patients between twenty-five and forty-five years of age, there were very few deaths, although there were a good many infarcts in the lungs in this group. Before we began doing Iigations, these were al1 treated conservatively and very

ALLEN-CIRCULATION AND TRAUMA

few of them died. In the older group beyond the age of forty-five, the number of fatal emboli was very much greater; the tendency in- creases as the patient grows oIder, so that we began Iigating the femoral vein in the older age group with greater frequency and with more feeIing of satisfaction than we now have when any patient of

any age group has any indication of phIebothrombosis or thrombo- phlebitis, since such a patient is subjected to Iigation without

further ado. It was thought that perhaps we couId be inteIIigent and scientific

about seIecting these patients for vein Iigations. Venography is now quite a we11 estabIished method of outIining the veins and it gradu- aIIy became used in the study of these patients. It was beIieved at the time that Drs. Faxon, Welch and McGahey sent their paper in for pubIication, that perhaps venography shouId be done pretty often in a doubtfu1 or borderIine case. AIthough venography is stiJ1 done, I wish to say that we are not quite so sure that it is a com-

pIeteIy reIiabIe test and we know, with the X-ray Department shorthanded as they are, that it puts an extra burden on them which perhaps in the future we may usuaIIy avoid. The method of venog- raphy is we11 described in the article referred to above and when such a test is definitely positive, one is greatIy assured that Iigation is indicated. If, on the other hand, it is negative, one may fee1 with a clear conscience that the veins need not be Iigated. The diffIcuIty with the method is that in some instances the vein has appeared normal and yet the patient has had an emboIus; and some of the veins that have been explored and Iigated in the presence of a normal venogram have shown thrombosis in the vein. On the other hand, some of the venograms, that have shown no flIing whatever in the

deep veins, have misIed us in that at operation the vein has been found compIeteIy free of any thrombus.

When muItipIe emboli have occurred, the patient may we11 deveIop considerabIe diffIcuIty in his chest which continues even after vein Iigation. In instances in which veins that have appeared to be norma have been Iigated, the infarcts have continued always subIetha1, Ieading one to assume that these infarcts may we11 have come from the neighborhood of a wound and wouId never have proved fatal under any circumstances. Such patients sometimes are heIped by heparin, aIthough our experience with heparin here has not been as spectacuIar as it has been in Toronto. So far we have had no experience with dicoumarin and this may eventually prove to be a tremendous heIp in this fieId.

ALLEN-CIRCULATION AND TRAUMA 181

There is one very definite feature that I think shouId be stressed and that is the Iigation of both femoraI veins rather than the one that appears to be invoIved. We have expected the misfortune of Jigating the vein on the side that was obviousIy involved with thrombophIebitis onIy to have the patient succumb to fata puI- monary emboIus, and to find at autopsy that the thrombus that had produced the emboIus had come from the supposed norma side. Therefore, there is some argument that if one Iigates the obviously invoIved vein, one must then very seriousIy consider Iigating the supposed norma side. This biIatera1 Iigation is being carried out here now with more and more frequency.

The technic of the operation is extremeIy simpIe: Under IocaI anesthesia guided by the pulsation of the femora1 artery, one makes a zf$ to 3 inch incision over the course of the vein, starting in the crease of the groin. The Iong saphenous vein is investigated and if this is found not to be thrombosed and not varicosed, it is Ieft aIone. The femora1 vein is exposed in the short space that is free beIow the profunda femoris. One can then pass two chromic catgut Iigatures under the vein, Ieaving them untied but heId by hemostats so that the bIeeding can be controIIed after the vein is opened. If one opens the vein transverseIy through haIf its diameter, Ieaving the posterior third or half of the vein intact, the manipuIation is aImost as easy as if the vein was compIeteIy divided and the contro1 of bIeeding from the vein, by hoIding up on the previousIy pIaced catgut ligatures, simpIifies the procedure. After opening the vein, cIots wiI1 exude from it and by using a gIass-tipped TrendeIenburg suction apparatus or a simpIe glass drinking tube, one can with suction puI1 the cIot from the region of the iIiac vein. After one has got a11 of this clot out, there shouId be free bIeeding from the proxima1 segment. This bleeding is kept under control then by the eIevation of the upper Iigature. Then cIot is miIked and sucked from the dista1 segment of the vein, removing as much of it as possible. Frequently enough, cIots from above and beIow put together may measure I 6 or I 8 inches in Iength. If one succeeds in getting the cIot from the Iower segment of the vein so that free bIeeding takes pIace from beIow, the resulting edema from the Iigation wiI1 be greatIy diminished and the con- vaIescence thereby wiI1 be shortened. After removing the cIot from the vein, one simpIy ties the Iigatures previousIy placed and then transfixes the vein with a cotton or siIk suture dista1 to the catgut tie in order to insure cIosure of the vein in this region. One may Ieave the posterior half or third of the vein intact, thereby Jigating the vein

182 ALLEN-CIRCULATION AND TRAUMA

more or less in continuity, or divide it. It seems to make no difference which method is adopted. We have reason to suppose that in time nature re%tabIishes circulation through this tied-off vein, as we have venograms that would seem to prove that this actually did occur.

After ligation other things being equal as regards difficulty from the infarcts in the chest or the operative wound originalIy made, one may with perfect impunity make these patients ambulatory just as soon as their temperature is normaI. It is a great comfort to be abIe to get these people out of bed at the end of forty-eight to seventy-two hours and have them waIk about. They use at first an ace bandage on the Iower extremity from the foot to the knee and often take this home with them but rarely use it for more than three or four weeks. The smal1 amount of sweIIing which occurs after this time is so negIigibIe and so unimportant from their standpoint that they prefer not to bother with the bandages. We have noted that there was some tendency for superficia1 veins to increase in size, temporarily at Ieast, folIowing the ligation of the femoraI vein itself.

I am perfectly certain that time will finally settIe the matter in a little more satisfactory fashion than it appears to be today. At the moment, I know we are ligating a great many veins that would not be the source of a fata puImonary embohsm. I would suppose that perhaps we may save six lives out of each hundred patients on whom we do vein Iigations. This is a definitely worth while saIvage but with more experience and a more carefu1 anaIysis, perhaps more useful standards of indications, we may be able to seIect these patients better and reduce the number of Iigations with a consequently higher ratio of rescues. At the moment, it is difficult to persuade our medical coIleagues that every infarct of the chest shouId not have immediate biIatera1 femora1 ligation. We are at a loss to know how to answer this other than to comply with their request because, in the first pIace, we must admit that this is not a serious operation; it does not produce a serious handicap to the patient afterward; and, of course, at the moment we have no way of teIIing whether or not that partic- uIar patient would deveIop a massive emboIus if his veins were left intact. There are many probIems to be settIed and one, I am sure, is how can we teI1 whether the infarct has not come from the heart, from the operative site, or from some smaIIer vein in the body other than the ones that are Iarge enough to produce the amount of thrombus necessary to occIude the puImonary artery compIeteIy. We beIieve, in time, that many of these questions wiI1 be soIved; we pIan a further anaIysis of our experience which is now getting greater

ALLEN-CIRCULATION AND TRAUMA 183

day by day. I think it is probably safe to say that at this time we

have ligated already in this HospitaI approximately 130 veins and

this wouId probabIy represent about 125 patients. At the rate we are

going, it wiII not be Iong before our experience wiI1 be very large. We

know that it is an operation that can be done simpIy and easiIy; it

takes aImost nothing out of a very ill patient. It requires twenty to

thirty minutes of time for each side, and the results in some instances

are so spectacujar that we beIieve it well worth while. In addition to

the prevention of fatal embolus in the cases of thrombophIebitis, we

find that the sweIling and the pain resolves very much more quickI!,

foIlowing the opening of the vein, the remova of the cIot, and the

ligation of the vein, than it would under ordinary circumstances.

Patients, who used to remain in bed for six weeks to recover from a

thrombophlebitis, would often be able to Ieave the hospita1 under

these circumstances within a week.

REFERENCES

I. WELCI-I, CLAUDE E., FAXON. HENRY H. and MCGAHEY, C. E. The adication of

phlebography to the therapy of thrombosis and embolism. Surger~i, 12: 163-183,

‘942. 2. ~~OMANS, JOHN. Exploration and division of the femoral and iliac veins in the treat-

ment of thrombophlebitis of the leg. New England J. Med., 224: 179, 1941. 3. DAVIS, LINCOLN. Personal communications re. chapter by Allen, A. W. Nelson’s

Loose-Leaf Surgery on Vascular Disease, July ,931. 4. WELCH, C. E. and FAXON, H. l-1. Thrombophlebitis and pulmonary embolism.

J. A. M. A., I 17: 1502-1508, 1941. 5. OCHSNER, AI-TON. Thrombophlebitis. Surgeon, 6: 129, ,030.

QUESTIONS AND ANSWERS

E. PAYNE PALMER (Phoenix, Arizona): I should like to ask Dr. Allen if he has had to go into the iliac vein to ligate in any of his cases. We have had to do so in two and found the clot rather extensive when we opened up the femoral. Therefore, we made the Cameron incision, pushed the curtain in

back and went back of the clot into the iliac. DK. ALLEN: I know a doctor who has done that several times, and we

have supposed that we might have to do likewise. He used that method of removal of the clot, but if you get the upper segment of the clot out, I think

you need not fear fatal embolism. Any thrombus remaining above the ligature would probably stay there and not go to the lungs.

DR. PALMER: How do you know you are going to get it all out? DR. ALLEN: I do not think it matters. You may get a smaIl infarct as we

did once in thirty-nine cases, but it is not fatal. What you are trying to avoid is enough cIot going to the puImonary artery to cause death, and this does it. Incidentally, interrupting the fIow in the vein is very effectively done by the ligation of the femoral vein at this point.

184 ALLEN-CIRCULATION AND TRAUMA

Dr. Darrach asked me why an inverse incision instead of a Iongitudinal one. You have not much room unless you tie off smaI1 veins that are going into the muscIes. There is about a centimeter between the profunda and muscIe branches, which is enough if you use a transverse incision.

FREDERIC W. BANCROFT (New York City) : Might I ask Dr. AIIen what resuIt he had had from bIocking the sympathetic?

DR. ALLEN: We have not had as good luck with it as they have had in New OrIeans. I think we have a different kind of thrombophIebitis here on the East Coast. I mean that, I have been down there and seen these cases and know they do hav.e exceIIent resuIts with this method, but our phIebitis, once it starts, is a diffrcuIt one to contro1. It takes six weeks to get over it; however, we have used this method very extensively and we think it has heIped a great deal. It is one of the methods we would use if we were not going to Iigate. Patients object to having their backs stuck too many days in succession and their phIebitis Iasts too Iong here to make us beIieve we shouId depend upon that method aIone.

KELLOGG SPEED (Chicago, IIIinois) : Have you used Dicoumarin at aII? DR. ALLEN: I have had absoIuteIy no experience with it. I do not know

whether that is going to be effective or not, but I hope so. DR. SPEED: It is very effective, at Ieast in cases I have seen. FRASER B. GURD (MontreaI, Canada): We have used Dicoumarin for

the last eight or nine months, and we are of the opinion that it is usefu1, and as compared with heparin it costs onIy five cents a day.

DR. ALLEN: You say it is usefuI? DR. GURD: As compared with heparin it seems to be as usefu1. It is given

by mouth, and two or three days’ administration Iasts for about two weeks. The only objection that we can see is that you cannot get your cIotting time back once you have compressed it, as compared with heparin.

DR. ALLEN: I do not think we have used it in this hospital as yet. DR. GURD: I do not think it is on the market. DR. SPEED: It is onIy being given out experimentahy. WILLIAM L. ESTES, JR. (BethIehem, Pa.): How Iong have you kept the

patients inactive after Iigation of the femoraI vein? DR. ALLEN: Everything eIse considered, forty-eight hours is enough,

unIess there are other reasons for a Ionger period. If the patient is febriIe stiI1 from his infarction, one should naturaIIy keep him quiet Ionger, but forty-eight hours is sufficient in the case of the ordinary patient. For instance, the one upon whom I think I did the unnecessary Iigation, I got out of bed the next day.

WILLIAM DARRACH (New York, N. Y.): How much do they sweII up afterward?

DR. ALLEN: Very IittIe if you Iigate them below the profunda. G. GAVIN MILLER (MontreaI, Canada): Dr. AIlen said he had had no

deaths foIIowing Iigation. I shouId Iike to report one. We had a patient with

ALLEN-CIRCULATION AND TRAUMA

an infarct; we ligated, and a few days Iater he died of embohsm. We aIso had

a death foIlowing Iigation within six days. DR. ALLEN: Were you able to get an autopsy on the patient that died?

Do you know for certain that the fata part of the embolus came from the

side you Iigated? DR. MILLER: No.

DR. ALLEN: We have been pretty lucky along that Iine, because I am

perfectIy certain that patients are going to die from the side that we have not ligated. This fear has made us more wiIIing to do biIatera1 Iigations.

H. GURTH PRETTY (Montreal, Canada): Do you Iind any increase in the number of these cases as the result of using cyclopropane?

DR. ALLEN: CycIopropane has not been used in this hospita1 since the

fata expIosion that occurred in Boston. The trustees did the same thing about ethyIene. We had three or four minor expIosions with that and they

said, “You cannot have it any more,” just about the time we had become

fond of it; and the same thing happened with cyclopropane. We have not used any for a number of years. I had not realized it wouId increase this

condition. DR. PRETTY: In Iooking up a great many cases of pulmonary emboli, we

found that the great majority of cases in various hospitals occurred foIIow-

ing spina anesthesia; next in order were those foIIowing cyclopropane, and

next in order those following open ether, on account of the sIowing of the

blood stream postoperatively.

DR. ALLEN: I cannot quote you the exact figures, but when Faxon looked over our fata cases of emboIi prior to the beginning of this recent

work, he sorted them out as to the kind of anesthetic agent that had been

used and came to the concIusion that here, at Ieast, we couId not see that it made any difference. The greatest percentage from any department came

from the uroIogica1 service, probably because they were dealing with a much older age group.