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Badalamenti G, Ferrer C, Calvagna C, Franchin M, Piffaretti G, Taglialavoro J, Bassini S, Griselli F, Grando B, Lepidi S, D'Oria M. Major vascular traumas to the neck, upper limbs, and chest: Clinical presentation, diagnostic approach, and management strategies. Semin Vasc Surg 2023; 36:258-267. [PMID: 37330239 DOI: 10.1053/j.semvascsurg.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 04/14/2023] [Accepted: 04/17/2023] [Indexed: 06/19/2023]
Abstract
Major vascular traumas to the neck, upper limbs, and chest may arise from penetrating and/or blunt mechanisms, resulting in a range of clinical scenarios. Lesions to the carotid arteries may also lead to neurologic complications, such as stroke. The increasing use of invasive arterial access for diagnostic and/or interventional purposes has increased the rate of iatrogenic injuries, which usually occur in older and hospitalized patients. Bleeding control and restoration of perfusion represent the two main goals of treatment for vascular traumatic lesions. Open surgery still represents the gold standard for most lesions, although endovascular approaches have increasingly emerged as feasible and effective options, particularly for management of subclavian and aortic injuries. In addition to advanced imaging (including ultrasound, contrast-enhanced cross-sectional imaging, and arteriography) and life support measures, multidisciplinary care is required, particularly in the setting of concomitant injuries to the bones, soft tissues, or other vital organs. Modern vascular surgeons should be familiar with the whole armamentarium of open and endovascular techniques needed to manage major vascular traumas safely and promptly.
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Affiliation(s)
- Giovanni Badalamenti
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Strada di Fiume 447, Trieste, Italy
| | - Ciro Ferrer
- Vascular and Endovascular Surgery Unit, 90352 San Giovanni - Addolorata Hospital, Roma, Italy
| | - Cristiano Calvagna
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Strada di Fiume 447, Trieste, Italy
| | - Marco Franchin
- Vascular Surgery Unit, Circolo University Teaching Hospital, University of Insubria - ASST Settelaghi, Varese, Italy
| | - Gabriele Piffaretti
- Vascular Surgery Unit, Circolo University Teaching Hospital, University of Insubria - ASST Settelaghi, Varese, Italy
| | - Jacopo Taglialavoro
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Strada di Fiume 447, Trieste, Italy
| | - Silvia Bassini
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Strada di Fiume 447, Trieste, Italy
| | - Filippo Griselli
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Strada di Fiume 447, Trieste, Italy
| | - Beatrice Grando
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Strada di Fiume 447, Trieste, Italy
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Strada di Fiume 447, Trieste, Italy
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Strada di Fiume 447, Trieste, Italy.
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Case report: Endovascular embolization of the thoracoacromial branch of axillary artery after gunshot trauma at a regional trauma center. Int J Surg Case Rep 2022; 94:107041. [PMID: 35439725 PMCID: PMC9026579 DOI: 10.1016/j.ijscr.2022.107041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/03/2022] [Accepted: 04/03/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction and importance Penetrating subclavian-axillary artery injury is a rare vascular injury associated with high morbidity and mortality rates traditionally treated with open surgical repair, however endovascular treatments have been utilized in selected cases. Case presentation We report a case of a 31-year-old male with a traumatic gunshot injury to the thoracoacromial branch of the left axillary artery successfully managed with endovascular embolization at a regional trauma center. Clinical discussion The availability of a hybrid operating suite in severely injured patients is associated with reduced time to intervention, reduced operative duration and improved clinical outcomes. Our experience demonstrates the utility and benefit of a hybrid operating theatre in a regional trauma center. The availability of a hybrid suite allowed rapid diagnostic and therapeutic angiography with a minimally invasive approach and eliminated the need for urgent open surgical management. However, the high costs associated with a hybrid operating theatre remain the major barrier for most regional centers. Conclusion The availability of hybrid operating theatre at a regional trauma center allowed early diagnosis and successful management of the injury with a minimally invasive endovascular approach. Subclavian-axillary artery injury is rare but carries a high morbidity and mortality. Endovascular repairs are effective in selected patients. The availability of a hybrid theatre is associated with improved clinical outcomes. The costs remain a challenge for most regional centers.
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Zhang J, Basu R, Bauder AR, Quatramoni JG, Glaser J, Kalapatapu V, Gaffey AC. Endovascular repair of traumatic axillosubclavian artery injuries. J Vasc Surg Cases Innov Tech 2022; 8:23-27. [PMID: 35036668 PMCID: PMC8743185 DOI: 10.1016/j.jvscit.2021.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 11/22/2021] [Indexed: 11/29/2022] Open
Abstract
Gun violence reached a 20-year peak in 2020, with the first-line treatment of axillosubclavian vascular injuries (SAVIs) remaining unknown. Traditional open exposure is difficult and exposes patients to iatrogenic venous and brachial plexus injury. The practice of endovascular treatment has been increasing. We performed a retrospective analysis of SAVIs at a level I trauma center. Seven patients were identified. Endovascular repair was performed in five patients. Technical success was 100%. The early results suggest that endovascular treatment of trauma-related SAVIs can be performed safely and effectively. However, complications such as stent thrombosis or occlusion can occur, demonstrating the need for surveillance.
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Affiliation(s)
- Jason Zhang
- Division of Vascular and Endovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Rohan Basu
- Division of Vascular and Endovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Andrew R. Bauder
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | | | - Julia Glaser
- Division of Vascular and Endovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Venkat Kalapatapu
- Division of Vascular and Endovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Ann C. Gaffey
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, School of Medicine, La Jolla, Calif
- Correspondence: Ann C. Gaffey, MD, MS, Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, School of Medicine, 9434 Medical Center Dr, Mail Code 7403, La Jolla, CA 92037
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Abstract
BACKGROUND Our aim was to identify predictors of mortality and limb loss in iatrogenic and civilian arterial trauma. METHODS Cases were identified by searching prospectively maintained registries. Multivariable logistic regression was used to identify independent outcome predictors. RESULTS During the study period, 285 patients with arterial trauma were managed with endovascular (n = 20) or open (n = 265) repair. Iatrogenic injuries increased in frequency during the course of the study, from 23.9% during the first decade to 35.9 and 55.7% during the second and third decade, respectively (p < 0.001). Endovascular management increased in frequency during the course of the study, from 0% during the first decade to 5.1 and 11.1% during the second and third decade, respectively (p = 0.005). Mortality was 9.8%, and limb loss (in cases with injury of the aorta or limb arteries, n = 259) was 6.2%. Independent predictors of mortality included increased age (odds ratio, 95% confidence interval [OR, 95% CI] 1.05 (1.02-1.07), p < 0.001), blunt trauma (OR [95% CI] 4.8 (1.9-12.2), p = 0.001) and the number of RBC units transfused intraoperatively (OR [95% CI] 1.25 (1.1-1.4), p = 0.001). Independent predictors of limb loss included the first half of the study period (OR [95% CI] 3.9 (1.1-14.1), p = 0.04), lower extremity arterial trauma (vs upper extremity, aortic, common or external iliac artery trauma, OR [95% CI] 8.3 (1.9-35.7), p = 0.004), bone fracture (OR [95% CI] 16.9 (4.7-62.5), p < 0.001) and the number of RBC units transfused intraoperatively (OR [95% CI] 1.16 (1.02-1.33), p = 0.024). CONCLUSION Increasingly iatrogenic in cause and managed by endovascular methods, arterial trauma remains a problem associated with significant mortality and limb loss. Identification of unfavourable outcome predictors may help clinicians involved with arterial trauma to escalate the level of care.
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Tadayon N, Yavari N, Zarrintan S, Hosseini SM, Kalantar-Motamedi SMR. Management of traumatic subclavian artery injuries in a high-volume vascular surgery center in Iran. J Cardiovasc Thorac Res 2020; 12:145-149. [PMID: 32626556 PMCID: PMC7321003 DOI: 10.34172/jcvtr.2020.24] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 01/30/2020] [Indexed: 11/29/2022] Open
Abstract
Introduction: Subclavian artery injury is an uncommon vascular trauma with potential morbidity and mortality. Management of subclavian artery trauma requires open and endovascular techniques and timely and efficacious decision is mandatory. We retrospectively reviewed traumatic subclavian artery injuries in a high-volume vascular surgery center in Iran.
Methods: In a retrospective study, we assessed subclavian artery injuries during 6 years in ShohadaTajrish Medical Center. Background characteristics, type of incision, type of operation and outcome of patients were evaluated.
Results: A total of 14 patients had subclavian artery injury (mean age 29.9 ± 13.4 years, 92.9% male). Trauma was in left and right sides in eight (57.1%) and six patients (42.9%) respectively. Arteriorrhaphy, interposition and ligation of injured artery was done in 7 (50.0%), 3 (21.4%) and 4 (28.6%) patients respectively. Associated nerve injury was present in six patients (42.9%). Endovascular proximal control was obtained in six patients (42.9%) prior to vascular exposure. Time of patient referral did not have significant association with shock or type of operation (P > 0.05).
Conclusion: Although traumatic subclavian artery injuries are rare, its vascular exposures and reconstructions are of potential clinical concern. Endovascular interventions can facilitate proximal control. In addition, endovascular repair by covered stent is an alternative to open surgery.
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Affiliation(s)
- Niki Tadayon
- Division of Vascular & Endovascular Surgery, Department of General & Vascular Surgery, Shohada-Tajrish Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Iranian Society of Vascular Surgery, Tehran, Iran
| | - Negin Yavari
- Research Department, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Sina Zarrintan
- Division of Vascular & Endovascular Surgery, Department of General & Vascular Surgery, Shohada-Tajrish Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Iranian Society of Vascular Surgery, Tehran, Iran.,Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Seyed Masoud Hosseini
- Division of Vascular & Endovascular Surgery, Department of General & Vascular Surgery, Shohada-Tajrish Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Iranian Society of Vascular Surgery, Tehran, Iran
| | - Seyed Moahammad Reza Kalantar-Motamedi
- Division of Vascular & Endovascular Surgery, Department of General & Vascular Surgery, Shohada-Tajrish Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Iranian Society of Vascular Surgery, Tehran, Iran
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O'Connor JV, Moran B, Galvagno SM, Deane M, Feliciano DV, Scalea TM. Admission Physiology vs Blood Pressure: Predicting the Need for Operating Room Thoracotomy after Penetrating Thoracic Trauma. J Am Coll Surg 2020; 230:494-500. [PMID: 32007533 DOI: 10.1016/j.jamcollsurg.2019.12.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 12/16/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Approximately 15% of patients with penetrating thoracic trauma require an emergency center or operating room thoracotomy, usually for hemodynamic instability or persistent hemorrhage. The hypothesis in this study was that admission physiology, not vital signs, predicts the need for operating room thoracotomy. STUDY DESIGN We conducted a trauma registry review, 2002 to 2017, of adult patients undergoing operating room thoracotomy within 6 hours of admission (emergency department thoracotomies excluded). Demographics, injuries, admission physiology, time to operating room (OR), operations, and outcomes were reviewed. Data are reported as mean (SD) or median (IQR). RESULTS Of the 301 consecutive patients in this 15-year review, 75.6% were male, mean age was 31.1 years (11.5), and 41.5% had gunshot wounds. The median Injury Severity Score was 25 (range 16 to 29), time to operating room was 38 minutes (interquartile range [IQR] 19 to 105 minutes), and 21.9% had a thoracic damage control operation. Mean admission systolic blood pressure was 115 mmHg (SD 37 mmHg), with only 23.9% <90 mmHg; however, admission pH 7.22 (SD 0.14), base deficit 7.6 (SD 6.1), and lactate 7.2 (SD 4.5) were markedly abnormal. Overall, there were 136 (45.2%) patients with significant pulmonary injuries treated with 112 major nonanatomic resections, 17 lobectomies, and 7 pneumonectomies; respective mortalities were 2.7%, 11.8%, and 42.9%. There were 100 (33.2%) cardiac, 30 (9.9%) great vessel, 14 (4.7%) aerodigestive, and 58 (19%) combined thoracic injuries. Mortalities for cardiac, great vessel, and aerodigestive injuries were 7%, 0%, and 14.3%, respectively. Overall mortality was 6.6%, 15.2% after damage control, and 4.3% for all others. CONCLUSIONS Shock characterized by acidosis, but not hypotension, is the most common presentation in patients who will need operating room thoracotomy after penetrating thoracic trauma. Survival rates are excellent unless a pneumonectomy or damage control thoracotomy is required.
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Affiliation(s)
- James V O'Connor
- Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD.
| | - Benjamin Moran
- Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Samuel M Galvagno
- Department of Anesthesia, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Molly Deane
- Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - David V Feliciano
- Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Thomas M Scalea
- Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
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Penetrating Subclavian Artery Injuries: Recent Challenges with Variable Solutions. Am Surg 2019. [DOI: 10.1177/000313481908500811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Glaser JD, Kalapatapu VR. Endovascular Therapy of Vascular Trauma—Current Options and Review of the Literature. Vasc Endovascular Surg 2019; 53:477-487. [DOI: 10.1177/1538574419844073] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Objective: To review the current use of endovascular techniques in trauma. Summary Background Data: Multiple studies have demonstrated that, despite current guidelines, endovascular therapies are used in instances of arterial trauma. Methods: The existing literature concerning arterial trauma was reviewed. Studies reviewed included case reports, single-center case series, large database studies, official industry publications and instructions for use, and society guidelines. Results: Endovascular therapies are used in arterial trauma in all systems. The use of thoracic endografts in blunt thoracic aortic trauma is accepted and endorsed by society guidelines. The use of endovascular therapies in other anatomic locations is largely limited to single-center studies. Advantages potentially include less morbidity due to smaller incisions as well as shorter operating room times. Many report using endovascular therapies even with hard signs of injury. Long-term results are limited by a lack of long-term follow-up but, in general, suggest that these techniques produce acceptable outcomes. The adoption of these techniques may be limited by resource and surgeon availability. Conclusions: The use of endovascular therapies in trauma has gained acceptance despite not yet having a place in official guidelines.
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Affiliation(s)
- Julia D. Glaser
- Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Venkat R. Kalapatapu
- Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia, PA, USA
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Eighteen years' experience of traumatic subclavian vascular injury in a tertiary referral trauma center. Eur J Trauma Emerg Surg 2019; 45:973-978. [PMID: 30627733 PMCID: PMC6910889 DOI: 10.1007/s00068-018-01070-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 12/27/2018] [Indexed: 11/09/2022]
Abstract
Purpose Traumatic subclavian vascular injury (TSVI) is rare but often fatal. The precise diagnosis of TSVI remains challenging mainly because of its occult nature, less typical presentations, and being overlooked in the presence of polytrauma. Compared to penetrating injuries, it is even more difficult to identify TSVI in patients who have blunt injuries and no visible bleeding. The risk factors associated with TSVI in patients with thoracic trauma are unclear. The aims of this study were to identify risk factors for TSVI in a cohort of patients with thoracic vascular injuries and to report outcomes after clinical treatment. Methods From January 2009 to June 2017, 39586 patients were admitted to our hospital (a level I trauma center) due to trauma, and 136 patients with thoracic vascular injury were enrolled in this study. We retrospectively reviewed data from medical records including demographic characteristics, injury scoring systems (RTS, ISS, NISS, TRISS and AIS), management and outcomes. Patients were further divided into the TSVI group (patients with TSVI) and the non-TSVI group (patients with thoracic vascular injuries other than TSVI). Univariate and multivariate analyses were used to identify independent risk factors. Results The enrolled 136 patients suffered mostly from blunt trauma (89.0%) and 22 of them had TSVI. When compared to the non-TSVI group, the TSVI group had lower Glasgow Coma Scale (GCS) scores (p = 0.002; especially GCS ≤ 12), less concurrent abdominal injury (p < 0.001), lower Injury Severity Scales (ISS) (p = 0.007) and New Injury Severity Scales (NISS) (p < 0.002) but had higher Abbreviated Injury Scales (AIS) of the head ≥ 3 (p = 0.009) and rates of clavicular or scapular fractures (p = 0.013). No difference was detected between the two groups with regard to age, gender, trauma mechanism, vital signs on arrival, or rate of facial and extremities injury. In multivariate regression analyses, GCS ≤ 12, AIS of the head ≥ 3 and the presence of clavicular or scapular fractures were independent risk factors for TSVI (p = 0.026, p = 0.043 and p = 0.005, respectively) after adjustment for confounding factors. Open and endovascular repair were two surgical procedures utilized for these TSVI patients with an overall mortality rate of 18.2%. No difference was found between these groups with regard to mortality rate and the length of ICU stay, but the patients in the TSVI group had a shorter length of hospital stay. Conclusions Our results suggest that GCS ≤ 12, AIS of the head ≥ 3 and the presence of clavicular or scapular fractures were independent risk factors for TSVI in patients with thoracic vascular injuries. For patients with thoracic trauma, TSVI should be considered for prompt management when patients exhibit concurrent injuries to the head, clavicle or scapula.
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Intraoperative combination of resuscitative endovascular balloon occlusion of the aorta and a median sternotomy in hemodynamically unstable patients with penetrating chest trauma: Is this feasible? J Trauma Acute Care Surg 2018; 84:752-757. [DOI: 10.1097/ta.0000000000001807] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Rayamajhi S, Murugan N, Nicol A, Edu S, Klopper J, Naidoo N, Navsaria P. Penetrating femoral artery injuries: an urban trauma centre experience. Eur J Trauma Emerg Surg 2018; 45:909-917. [PMID: 29619536 DOI: 10.1007/s00068-018-0951-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 03/30/2018] [Indexed: 11/29/2022]
Abstract
AIM This study reviews a single centre experience with penetrating femoral artery injuries. PATIENTS AND METHODS The records of all patients with femoral artery injuries admitted to the Trauma Centre at Groote Schuur Hospital from January 2002 to December 2012 were reviewed. These were analysed for demographics, injury mechanism, perioperative, and surgical management. Outcome was categorised by limb salvage. RESULTS One-hundred and fifty-eight (158) patients with femoral artery injuries were identified. There were 144 (91%) men and 14 women with a mean age of 28 years. Ninety-five percent (N = 150) sustained penetrating injuries. The superficial femoral artery (87%) was most commonly injured. The most common type of arterial injury was a laceration (39%) and transection (37%). Eighty-one (51%) patients had a primary repair, 53 (33%) patients had a vein interposition graft, and 16 patients (10%) had a prosthetic graft. There were 78 (51%) concomitant venous injuries, 11 were repaired, and 1 vein patch repair was performed (15.4%). There were 4 (2.5%) primary amputations and 10 (6.5%) secondary amputations. There were no deaths. Statistically significant risk factors for secondary amputation derived by univariate analysis were: ischaemia (p < 0.0001), neurological deficit due to ischemia (p < 0.001), temporary vascular shunting (p < 0.001), and the absence of a palpable pulse post-repair (p < 0.01). CONCLUSION This study has a primary and secondary amputation rate of 2.5 and 6.5%, respectively. There was greater than 90% limb salvage rate. The outcome of threatened limbs due to femoral artery injury is good, provided that there is no delay to surgery.
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Affiliation(s)
- Shreya Rayamajhi
- Trauma Center-C14, Observatory, Groote Schuur Hospital, Cape Town, 7925, South Africa
- Department of Surgery, Groote Schuur Hospital, Cape Town, 7925, South Africa
- Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Nivashini Murugan
- Trauma Center-C14, Observatory, Groote Schuur Hospital, Cape Town, 7925, South Africa
- Department of Surgery, Groote Schuur Hospital, Cape Town, 7925, South Africa
- Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Andrew Nicol
- Trauma Center-C14, Observatory, Groote Schuur Hospital, Cape Town, 7925, South Africa
- Department of Surgery, Groote Schuur Hospital, Cape Town, 7925, South Africa
- Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Sorin Edu
- Trauma Center-C14, Observatory, Groote Schuur Hospital, Cape Town, 7925, South Africa
- Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Juan Klopper
- Department of Surgery, Groote Schuur Hospital, Cape Town, 7925, South Africa
- Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Nadraj Naidoo
- Department of Surgery, Groote Schuur Hospital, Cape Town, 7925, South Africa
- Division of Vascular Surgery, Groote Schuur Hospital, Cape Town, 7925, South Africa
- Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Pradeep Navsaria
- Trauma Center-C14, Observatory, Groote Schuur Hospital, Cape Town, 7925, South Africa.
- Department of Surgery, Groote Schuur Hospital, Cape Town, 7925, South Africa.
- Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
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Contemporary management of subclavian and axillary artery injuries-A Western Trauma Association multicenter review. J Trauma Acute Care Surg 2017; 83:1023-1031. [PMID: 28715360 DOI: 10.1097/ta.0000000000001645] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Subclavian and axillary artery injuries are uncommon. In addition to many open vascular repairs, endovascular techniques are used for definitive repair or vascular control of these anatomically challenging injuries. The aim of this study was to determine the relative roles of endovascular and open techniques in the management of subclavian and axillary artery injuries comparing hospital outcomes, and long-term limb viability. METHODS A multicenter, retrospective review of patients with subclavian or axillary artery injuries from January 1, 2004, to December 31, 2014, was completed at 11 participating Western Trauma Association institutions. Statistical analysis included χ, t-tests, and Cochran-Armitage trend tests. A p value less than 0.05 was significant. RESULTS Two hundred twenty-three patients were included; mean age was 36 years, 84% were men. An increase in computed tomography angiography and decrease in conventional angiography was observed over time (p = 0.018). There were 120 subclavian and 119 axillary artery injuries. Procedure type was associated with injury grade (p < 0.001). Open operations were performed in 135 (61%) patients, including 93% of greater than 50% circumference lacerations and 83% of vessel transections. Endovascular repairs were performed in 38 (17%) patients; most frequently for pseudoaneurysms. Fourteen (6%) patients underwent a hybrid procedure. Use of endovascular versus open procedures did not increase over the duration of the study (p = 0.248). In-hospital mortality rate was 10%. Graft or stent thrombosis occurred in 7% and graft or stent infection occurred in 3% of patients. Mean follow-up was 1.6 ± 2.4 years (n = 150). Limb salvage was achieved in 216 (97%) patients. CONCLUSION The management of subclavian and axillary artery injuries still requires a wide variety of open exposures and procedures, especially for the control of active hemorrhage from more than 50% vessel lacerations and transections. Endovascular repairs were used most often for pseudoaneurysms. Low early complication rates and limb salvage rates of 97% were observed after open and endovascular repairs. LEVEL OF EVIDENCE Prognostic/epidemiologic, level IV.
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du Toit T, Manning K, Naidoo NG. Upper limb ischaemia: a South African single-centre experience. Cardiovasc J Afr 2017; 29:88-92. [PMID: 29220060 PMCID: PMC6008899 DOI: 10.5830/cvja-2017-049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 11/17/2017] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE The aims of this study were to report on our experience with upper limb ischaemia (ULI), to define the pattern and distribution of disease, describe key demographic features and report on conventional clinical outcomes. METHODS This was a single-centre, retrospective, descriptive study. All patients (n = 64) who underwent a surgical intervention for ULI over a 12-year study period were included. Findings were analysed and compared with the current literature. RESULTS A male:female ratio of 0.60 was reported. Two major subgroups of patients were identified. The patients in the thrombo-embolic subgroup (n = 30) were notably younger than expected (mean age 55 years) compared to those in the atherosclerotic occlusive disease subgroup (n = 12, mean age 57 years). Presentation overall was generally late, with 8.6% of acute ULI and 48.3% of chronic ULI patients presenting with irreversible ischaemia and tissue loss, respectively. Thrombo-embolism was the dominant vascular pathology reported in this case series (47%). Ninety-five procedures were performed in 64 patients (89 open, six endovascular). Peri-operative (30-day) mortality rate was 7.8%. Systemic and procedure-related complications were observed in 13 and 23%, respectively. The overall major amputation rate was 10.9%. Adherence to follow up was poor (51% at six months). CONCLUSION Although few firm conclusions could be drawn, this review has expanded our overall perspective of ULI, specific to the population we serve. Collaboration between African vascular units should be encouraged in an attempt to further define the pattern of ULI by identifying distinct geographical confounders.
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Affiliation(s)
- Tinus du Toit
- Department of Surgery, Groote Schuur Hospital, Cape Town, South Africa.
| | - Kathryn Manning
- Department of Medicine, Groote Schuur Hospital, Cape Town, South Africa
| | - Nadraj G Naidoo
- Vascular Unit, Department of Surgery, Groote Schuur Hospital, Cape Town, South Africa
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Contemporary management of civilian penetrating cervicothoracic arterial injuries. J Trauma Acute Care Surg 2016; 81:302-6. [DOI: 10.1097/ta.0000000000001103] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Defining Zone I of penetrating neck trauma: A surgical controversy in the light of clinical anatomy. J Trauma Acute Care Surg 2016; 80:670-3. [PMID: 26808025 DOI: 10.1097/ta.0000000000000978] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Labsaili H, Makani S. [Wound of the left subclavian artery by a screwdriver: about a case]. Pan Afr Med J 2014; 18:75. [PMID: 25400842 PMCID: PMC4231247 DOI: 10.11604/pamj.2014.18.75.4281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 05/07/2014] [Indexed: 11/23/2022] Open
Abstract
Nous rapportons le cas d'un patient présentant une plaie de l'artère sous-clavière gauche suite à un traumatisme par un tournevis. Il s'agit d'une lésion rare mais grave, qui entraine souvent des complications neurologiques et respiratoires pouvant être mortelles. Dans les pays en voie de développement, la chirurgie classique à ciel ouvert reste de premier recours.
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Affiliation(s)
- Hicham Labsaili
- Service de Chirurgie Cardio-Vasculaire, CHU IBN ROCHD, Casablanca, Maroc
| | - Said Makani
- Service de Chirurgie Cardio-Vasculaire, CHU IBN ROCHD, Casablanca, Maroc
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Oliveira N, Alves G, Rodrigues H, Gonçalves FB, Martins J, Morais JA, Ferreira ME, Castro JA, Capitão LM. Endovascular treatment of blunt traumatic injuries of the subclavian and axillary arteries. ANGIOLOGIA E CIRURGIA VASCULAR 2014. [DOI: 10.1016/j.ancv.2014.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Kalish J, Nguyen T, Hamburg N, Eberhardt R, Rybin D, Doros G, Farber A. Associated venous injury significantly complicates presentation, management, and outcomes of axillosubclavian arterial trauma. Int J Angiol 2013; 21:217-22. [PMID: 24293980 DOI: 10.1055/s-0032-1330969] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Axillosubclavian vessel injury (ASVI) is associated with high morbidity and mortality. Most studies are single-center experiences of small numbers of patients with penetrating injury. We assessed 21st-century presentation and management of ASVI and focused on outcomes of combined arterial/venous injury. We reviewed the National Trauma Data Bank for patients with isolated arterial ASVI (group 1) and combined arterial/venous ASVI (group 2). Demographics, injury severity parameters, interventions, complications, and outcomes were compared. We identified 581 patients with ASVI (mean age 35.1; 88.1% male), with 466 isolated arterial injuries and 115 combined arterial/venous injuries. Group 2 had lower presenting systolic blood pressure and Glasgow Coma Scale, and had higher rates of operative repair (55.7 vs. 43.1%, p = 0.016) and higher mortality (33.9 vs. 13.9%, p < 0.001). There were no differences in amputation (5.2 vs. 2.4%, p = 0.121), compartment syndrome (2.6 vs. 1.9%, p = 0.713), and deep vein thrombosis (0.9 vs. 0.2%, p = 0.357). When separated by mechanism of injury, combined injuries from blunt trauma did increase amputation rates (27.8 vs. 4.2%, p = 0.002). Multivariate analysis revealed that combined arterial/venous injury significantly increased risk of death (odds ratio [OR], 2.99; confidence interval [CI], 1.73 to 5.17; p = 0.0001). Penetrating injury had higher odds of death than blunt injury (OR, 1.96; CI, 1.03 to 3.73; p = 0.041). ASVI is rare but extremely lethal. Concomitant venous and arterial injury is not associated with worse limb-related outcomes, except in blunt injuries and resultant amputations, but is associated with a threefold increase in mortality rates compared with isolated arterial injury.
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Affiliation(s)
- Jeffrey Kalish
- Division of Vascular and Endovascular Surgery, Boston University Medical Center, Boston, Massachusetts
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O'Reilly GM, Joshipura M, Cameron PA, Gruen R. Trauma registries in developing countries: a review of the published experience. Injury 2013; 44:713-21. [PMID: 23473265 DOI: 10.1016/j.injury.2013.02.003] [Citation(s) in RCA: 106] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2012] [Revised: 12/26/2012] [Accepted: 02/02/2013] [Indexed: 02/02/2023]
Abstract
BACKGROUND The burden of injury is greatest in developing countries. Trauma systems have reduced mortality in developed countries and trauma registries are known to be integral to monitoring and improving trauma care. There are relatively few trauma registries in developing countries and no reviews describing the experience of each registry. The aim of this study was to examine the collective published experience of trauma registries in developing countries. METHODS A structured review of the literature was performed. Relevant abstracts were identified by searching databases for all articles regarding a trauma registry in a developing country. A tool was used to abstract trauma registry details, including processes of data collection and analysis. RESULTS There were 84 articles, 76 of which were sourced from 47 registries. The remaining eight articles were perspectives. Most were from Iran, followed by China, Jamaica, South Africa and Uganda. Only two registries used the Injury Severity Score (ISS) to define inclusion criteria. Most registries collected data on variables from all five variable groups (demographics, injury event, process of care, injury severity and outcome). Several registries collected data for less than a total of 20 variables. Only three registries measured disability using a score. The most commonly used scores of injury severity were the ISS, followed by Revised Trauma Score (RTS), Trauma and Injury Severity Score (TRISS) and the Kampala Trauma Score (KTS). CONCLUSION Amongst the small number of trauma registries in developing countries, there is a large variation in processes. The implementation of trauma systems with trauma registries is feasible in under-resourced environments where they are desperately needed.
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Affiliation(s)
- Gerard M O'Reilly
- Victorian State Trauma Registry, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Commercial Road, Melbourne 3004, Australia.
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Sinha S, Patterson BO, Ma J, Holt PJ, Thompson MM, Carrell T, Tai N, Loosemore TM. Systematic review and meta-analysis of open surgical and endovascular management of thoracic outlet vascular injuries. J Vasc Surg 2013; 57:547-567.e8. [DOI: 10.1016/j.jvs.2012.10.077] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Revised: 09/26/2012] [Accepted: 10/04/2012] [Indexed: 10/27/2022]
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Assenza M, Centonze L, Valesini L, Campana G, Corona M, Modini C. Traumatic subclavian arterial rupture: a case report and review of literature. World J Emerg Surg 2012; 7:18. [PMID: 22710070 PMCID: PMC3447637 DOI: 10.1186/1749-7922-7-18] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2012] [Accepted: 06/18/2012] [Indexed: 11/14/2022] Open
Abstract
Subclavian artery injuries represent an uncommon complication of blunt chest trauma, this structure being protected by subclavius muscle, the clavicle, the first rib, and the deep cervical fascia as well as the costo-coracoid ligament, a clavi-coraco-axillary fascia portion. Subclavian artery injury appears early after trauma, and arterial rupture may cause life-treatening haemorrages, pseudo-aneurysm formation and compression of brachial plexus. These clinical eveniences must be carefully worked out by accurate physical examination of the upper limb: skin color, temperature, sensation as well as radial pulse and hand motility represent the key points of physical examination in this setting. The presence of large hematomas and pulsatile palpable mass in supraclavicular region should raise the suspicion of serious vascular injury. Since the first reports of endovascular treatment for traumatic vascular injuries in the 90’s, an increasing number of vascular lesions have been treated this way. We report a case of traumatic subclavian arterial rupture after blunt chest trauma due to a 4 meters fall, treated by endovascular stent grafting, providing a complete review of the past twenty years’ literature.
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Affiliation(s)
- Marco Assenza
- Emergency Department, Division of Emergency Surgery and Trauma, Policlinico "Umberto I", Rome, Italy.
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Fatimi SH, Deedar-Ali-Khawaja R, Niazi SK, Luqman Z. Late concomitant pseudoaneurysm and arteriovenous fistula of the subclavian artery: a developing country perspective. Vasc Endovascular Surg 2010; 44:503-5. [PMID: 20519279 DOI: 10.1177/1538574410372147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Concomitant subclavian artery pseudoaneurysm and arteriovenous (AV) fistula has been rarely reported. We report a case of late concomitant pseudoaneurysm and AV fistula of the subclavian artery caused by a gunshot wound. Open surgical approach with an infraclavicular approach was used; subclavian artery was repaired with a Gortex interposition graft and subclavian vein was ligated. The postoperative course was uneventful. In developing countries, where the endovascular expertise is unavailable or if the lesion is large, open surgical approach provides similar results as an endovascular approach.
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Affiliation(s)
- Saulat Hasnain Fatimi
- Section of Cardiothoracic Surgery, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan.
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