A Ten Year Review of Civilian Iliac Vessel Injuries from a Single Trauma Centre

[Endovascular Treatment for Vascular Injuries of the Extremities]

Vascular injuries of the extremities are associated with a high mortality rate. Conventionally, open surgery is the treatment of choice for peripheral vascular injuries. However, rapid development of devices and techniques in recent years has significantly increased the utilization and clinical application of endovascular treatment. Endovascular options for peripheral vascular injuries include stent-graft placement and embolization. The surgical approach is difficult in cases of axillo-subclavian or iliac artery injuries, and stent-graft placement is a widely accepted alternative to open surgery. Embolization can be considered for arterial injuries associated with active bleeding, pseudoaneurysms, and arteriovenous fistula and in patients in whom embolization can be safely performed without a risk of ischemic complications in the extremities. Endovascular treatment is a minimally invasive procedure and is useful as a simultaneous diagnostic and therapeutic approach, which serve as advantages of this technique that is widely utilized for vascular injuries of the extremities.

Role of Endovascular Stenting in Patients with Traumatic Iliac Artery Injury

BACKGROUND

Common and external iliac artery injuries (IAI) portend significant morbidity and mortality. The goal of this study was to examine the impact of mechanism of injury and type of repair on outcomes and identify the optimal repair for patients with traumatic IAI using a large, national dataset.

STUDY DESIGN

Patients undergoing operative repair for IAI were identified from the Trauma Quality Improvement Program database during a 5-year timespan, ending in 2019. Age, sex, race, severity of injury, severity of shock, type of iliac repair (open or endovascular), mechanism, morbidity and mortality were recorded. Patients with IAI were stratified by both type of repair and mechanism and compared. Multivariable logistic regression analysis was used to identify independent predictors of mortality.

RESULTS

Operative IAI was identified in 507 patients. Of these injuries, 309 (61%) were penetrating and 346 (68.2%) involved the external iliac artery. The majority of patients were male (82%) with a median age and ISS of 31 and 20, respectively. Endovascular repair was performed in 31% of cases. For patients with penetrating injuries, the type of repair impacted neither morbidity nor mortality. For blunt-injured patients, endovascular repair was associated with lower morbidity (29.3% vs 41.3%; p = 0.082) and significantly reduced mortality (14.6% vs 26.7%; p = 0.037) compared with the open-repair approach. Multivariable logistic regression identified endovascular repair as the only modifiable risk factor associated with decreased mortality (odds ratio 0.34; 95% CI 0.15 to 0.79; p = 0.0116).

CONCLUSIONS

Traumatic IAI causes significant morbidity and mortality. Endovascular repair was identified as the only modifiable predictor of decreased mortality in blunt-injured patients with traumatic IAI. Therefore, for select patients with blunt IAIs, an endovascular repair should be the preferred approach.

Early Outcomes of Complex Vascular Reconstructions in Lower Extremities Using Spiral and Panel Vein Grafts

BACKGROUND

Spiral saphenous vein grafts (SSVG) or paneled vein grafts (PVG) can be used when the diameter of the autologous great saphenous vein does not match the vessel that needs to be repaired. This study aimed to present early results of complex vascular reconstruction with SSVGs and PVGs in the lower extremities.

METHODS

From May 2019 through January 2021, 6 SSVGs and 3 PVGs were used for vascular reconstruction in 9 patients. Patient data were collected retrospectively, including age, gender, cause of vascular pathology, target vessels, concomitant injury, surgical method, additional surgical methods, and hemodynamic status. The Kaplan-Meier method was used to calculate the rate of freedom from reintervention.

RESULTS

Among these patients, 7 had trauma, 1 had graft infection, and 1 had vascular reconstruction after tumor excision. The mean duration of follow-up was 6 ± 6.6 months (range 1-19 months). The rate of freedom from reintervention for any reason was 77.8% at 1 year. Two patients underwent amputation after vascular reconstruction with patent vascular reconstructions. One of the 2 amputations was performed because of infection, and the other was due to ischemia >24 hr. The success rate of reconstruction was 100%, and the primary patency rate was 100%. The rate of limb salvage was 77.8%. There was no death, bleeding, embolism, skin ulcers, graft-related complication, or aneurysmal dilation during follow-up.

CONCLUSIONS

SSVG and PVG were associated with low infection rates and satisfactory short-term patency rates. Both 2 grafts may be good choices when there is a diameter mismatch in vascular reconstructions.

Successful Surgical Intervention of Strangulated Ileus with a Simple Cut of the External Iliac Vein without Vein Reconstruction

A 67-year-old woman with epigastralgia was referred to our hospital. The patient had undergone hysterectomy, bilateral oophorectomy, omentectomy, and radical pelvic and para-aortic lymph node dissection for her ovarian cancer 6 years before. Despite the gastrointestinal decompression therapy under the presumed diagnosis of adhesive ileus, computed tomography scans taken 3 days after the onset of epigastralgia showed marked dilatation of the small intestine and an oval high-density mass, that is, thrombi, in the right femoral vein. Aggravation of ileus with the thrombi in the femoral vein made us to treat the patient with surgery. Intraoperative findings showed that the terminal ileum was strangulated by a gap between the exposed right external iliac vein and artery presumably formed by pelvic lymph node dissection. Distal ileum strangulated by the gap, however, showed no ischemic change with no surgically available peritoneum left around the external iliac vein. To prevent the pulmonary embolism and the recurrence of this type of ileus due to both the thrombi and the persistent gap, we released the strangulated ileum with a simple cut of the external iliac vein without vein reconstruction. The patient recovered uneventfully and was discharged on the 13th day after operation. The patient has been well with nominal right leg edema. In this situation, that is, internal hernia caused by external iliac vessels with thrombi in the femoral vein and no leg edema, a simple cut of the external iliac vein without vein reconstruction is a feasible treatment option.

Repair of the Iliac Arterial Injury in Trauma: An Endovascular Operation?

BACKGROUND

Endovascular therapy is effective for non-traumatic iliac arterial diseases. The role of endovascular surgery in traumatic iliac lesions is unclear. The aim of this study is to compare outcomes for open versus endovascular management of traumatic iliac injuries.

MATERIALS AND METHODS

The National Trauma Data Bank was searched for patients from 2002to 2016 with iliac arterial injury. Patients were sorted by treatment modality (open versus endo) and mechanism (blunt versus penetrating) and matched using mangled extremity score variables. The proportion of patients undergoing amputation were compared using the chi-square test.

RESULTS

In the blunt group, 1550 (82%) had endovascular and 342 (18%) had open repair. Endovascular repair was associated with a significantly lower amputation rate than open repair (0.6% versus 3.6%, P = 0.015) despite higher incidence of concomitant injuries. Venous injury was more frequent in the open group (13.7% versus 1.8%, P < 0.001). Within the penetrating group, 209 (22%) had endovascular and 755 (78%) had open repair. Again endovascular repair was associated with a lower amputation rate (0% versus 5.1%, P = 0.004). Patients undergoing endovascular repair had more severe extremity/orthopedic injury, with venous injury again associated with open repair (48.5% versus 37.4%, P = 0.03).

CONCLUSIONS

Endovascular repair of iliac injuries was associated with a significantly lower rate of amputation than open surgery. Endovascular repair was associated with a higher incidence of several injuries, although open repair was associated with concomitant venous injury. Further work is required to delineate the benefit of endovascular intervention and role of venous injury in limb salvage.

American Association for the Surgery of Trauma-World Society of Emergency Surgery guidelines on diagnosis and management of abdominal vascular injuries

Abdominal vascular trauma accounts for a small percentage of military and a moderate percentage of civilian trauma, affecting all age ranges and impacting young adult men most frequently. Penetrating causes are more frequent than blunt in adults, while blunt mechanisms are more common among pediatric populations. High rates of associated injuries, bleeding, and hemorrhagic shock ensure that, despite advances in both diagnostic and therapeutic technologies, immediate open surgical repair remains the mainstay of treatment for traumatic abdominal vascular injuries. Because of their devastating nature, abdominal vascular injuries remain a significant source of morbidity and mortality among trauma patients. The American Association for the Surgery of Trauma in conjunction with the World Society of Emergency Surgery seek to summarize the literature to date and provide guidelines on the presentation, diagnosis, and treatment of abdominal vascular injuries. LEVEL OF EVIDENCE: Review study, level IV.

Damage Control Laparotomy: High-Volume Centers Display Similar Mortality Rates Despite Differences in Country Income Level

BACKGROUND

Comprehensive analysis of trauma care between high-, middle-, and low-income countries (HIC/MIC/LIC) is needed to improve global health. Comparison of HIC and MIC outcomes after damage control laparotomy (DCL) for patients is unknown. We evaluated DCL utilization among patients treated at high-volume trauma centers in the USA and South Africa, an MIC, hypothesizing similar mortality outcomes despite differences in resources and setting.

METHODS

Post hoc analysis of prospectively collected trauma databases from participating centers was performed. Injury severity, physiologic, operative data and post-operative outcomes were abstracted. Univariate and multivariable analyses were performed to assess differences between HIC/MIC for the primary outcome of mortality.

RESULTS

There were 967 HIC and 602 MIC patients who underwent laparotomy. DCL occurred in 144 MIC patients (25%) and 241 HIC (24%) patients. Most sustained (58%) penetrating trauma with higher rates in the MIC compared to the HIC (71 vs. 32%, p = 0.001). Between groups, no differences were found for admission physiology, coagulopathy, or markers of shock except for increased presence of hypotension among patients in the HIC. Crystalloid infusion volumes were greater among MIC patients, and MIC patients received fewer blood products than those in the HIC. Overall mortality was 30% with similar rates between groups (29 in HIC vs. 33% in MIC, p = 0.4). On regression, base excess and penetrating injury were independent predictors of mortality but not patient residential status.

CONCLUSION

Use and survival of DCL for patients with severe abdominal trauma was similar between trauma centers in HIC and MIC settings despite increased penetrating trauma and less transfusion in the MIC center. While the results overall suggest no gap in care for patients requiring DCL in this MIC, it highlights improvements that can be made in damage control resuscitation.

Abdominal vascular injuries: Blunt vs. penetrating

INTRODUCTION

Abdominal vascular injuries (AVIs) remain a great challenge since they are associated with significant mortality. Penetrating injury is the most common cause of AVIs; however, some AVI series had more blunt injuries. There is little information regarding differences between penetrating and blunt AVIs. The objective of the present study was to identify the differences between these two mechanisms in civilian AVI patients in terms of patient's characteristics, injury details, and outcomes.

METHOD

From January 2007 to January 2016, we retrospectively collected the data of AVI patients at King Chulalongkorn Memorial hospital, including demographic data, details of injury, the operative managements, and outcomes in terms of morbidity and mortality. The comparison of the data between blunt and penetrating AVI patients was performed.

RESULTS

There were 55 AVI patients (28 blunt and 27 penetrating). Majority (78%) of the patients in both groups were in shock on arrival. Blunt AVI patients had significantly higher injury severity score (mean(SD) ISS, 36(20) vs. 25(9), p = 0.019) and more internal iliac artery injuries (8 vs. 1, p = 0.028). On the other hand, penetrating AVI patients had more aortic injuries (5 vs. 0, p = 0.046), and inferior vena cava injuries (7 vs. 0, p = 0.009). Damage control surgery (DCS) was performed in 45 patients (82%), 25 in blunt and 20 in penetrating. The overall mortality rate was 40% (50% in blunt vs. 30% in penetrating, p = 0.205).

CONCLUSIONS

Blunt AVI patients had higher ISS and more internal iliac artery injuries, while penetrating AVI patients had more aortic injuries and vena cava injuries. Majority of AVI patients in both groups presented with shock and required DCS.

Endovascular Repair of Iliac Vein Laceration Associated with Complex Pelvic Fracture

BACKGROUND

Iliac vein injury associated with pelvic fracture due to blunt trauma is an uncommon and difficult diagnosis but a life-threatening condition which often requires an emergent management. Although open repair has been traditionally used as the treatment of choice in unstable patients, it is controversial, given the difficulty due to injured vessel exposure in patients with significant retroperitoneal hematoma as well as tamponade effect loss associated with laparotomy. We present a challenging case of iliac vein laceration successfully treated by placement of a self-expanding covered stent.

METHODS

A 15-year-old male was hemodynamically unstable and was transferred to our emergency department after a severe polytrauma due to a motorcycle accident. Contrast-enhanced computed tomography showed a left external iliac vein laceration with active bleeding and retroperitoneal hematoma as well as complex pelvic and left supracondylar femoral fractures. A 13 × 100 mm self-expanding covered stent was successfully deployed through duplex ultrasound-guided percutaneous approach of both femoral veins.

RESULTS

The patient's blood pressure was normalized as soon as the stent graft was placed, and then femoral fracture was reduced and fixed. At 12-month follow-up, the patient remained asymptomatic, and stent-graft patency was confirmed.

CONCLUSIONS

Covered stent-graft placement can be an effective and rapid treatment for life-threatening iliac vein injury.

Posttraumatic Reconstruction of External Iliac and Common Femoral Veins Using Femoral Vein Interposition Autograft

Posttraumatic reconstruction of large lower extremity veins is a challenging and rarely performed procedure. We describe a case of an 18-year-old male traffic accident victim presenting with extensive venous injury of the right inguinal region including external iliac vein and common femoral vein requiring immediate ligation. Owing to life-threatening phlegmasia cerulea dolens, venous reconstruction was successfully performed using an femoral vein interposition autograft from the contralateral lower limb.

Vascular Shunts in Civilian Trauma

Experience with temporary intravascular shunts (TIVS) for vessel injury comes from the military sector and while the indications might be clear in geographically isolated and under resourced war zones, this may be an uncommon scenario in civilian trauma. Data supporting TIVS use in civilian trauma have been extrapolated from the military literature where it demonstrated improved life and limb salvage. Few non-comparative studies from the civilian literature have also revealed similar favorable outcomes. Still, TIVS placement in civilian vascular injuries is uncommon and by some debatable given the absence of clear indications for placement, the potential for TIVS-related complications, the widespread resources for immediate and definitive vascular repair, and the need for curtailing costs and optimizing resources. This article reviews the current evidence and the role of TIVS in contemporary civilian trauma management.

Venous Shunt Versus Venous Ligation for Vascular Damage Control: The Immunohistochemical Evidence

BACKGROUND

To evaluate the expression of immunohistochemical markers of tissue ischemia (iNOS, eNOS, and HSP70) in a vascular damage control experimental model to determine if a venous temporary vascular shunt insertion leads to a better limb perfusion when compared with the ligature of the injured vein.

METHODS

Experimental study in male Sus Scrofa weighting 40 Kg. Animals were distributed into 5 groups: group 1 animals were submitted to right external iliac artery (EIA) shunting and right external iliac vein (EIV) ligation; group 2 animals were submitted to right EIA shunting and right EIV shunting; group 3 animals were submitted to right EIV ligation; group 4 animals were submitted to right EIV shunting; group 5 animals were not submitted to vascular shunting or venous ligation. Transonic Systems flowmeters were used to measure vascular flow on right and left external iliac vessels, and i-STAT (Abbot) portable blood analyzer was used for EIVs blood biochemical analysis. An initial baseline register of invasive arterial pressure, iliac vessels flow, and venous blood analysis was performed. Arterial pressure and iliac vessels flow were taken immediately after right iliac vessels shunting or ligation. Then, hemorrhagic shock was induced by continuous 20 mL/min blood withdraw from the external right jugular vein whereas arterial blood pressure and iliac vessels flow registers were taken every 10 min, and blood samples from EIVs were obtained every 30 min until the vascular flow through right EIA (or through the shunt inserted into the right EIV for group 4 animals) became inexistent or until the animal's death. After the end of the experiments, bilateral hind limb's biopsies were obtained for immunohistochemical analysis. Using image editing and analysis software, the expression of iNOS, eNOS, and HSP70 (3 well-known ischemic associated immunohistochemical markers) was assessed. The mean expression of each marker in the right hind limb was compared between groups. For statistical analysis, Microsoft Office Excel 2007 and BioEstat 5.0 (2007) were used.

RESULTS

Immunohistochemical analysis showed no difference regarding the iNOS expression; nevertheless, both eNOS and HSP70 expression were statistically more intense (P < 0.05) on group 1 (eNOS = 1.32; HSP70 = 15.05) than on group 2 (eNOS = 0.018; HSP70 = 8.56).

CONCLUSIONS

The higher expression of eNOS and HSP70 in the right hind limbs of group 1 animals (arterial shunt and venous ligature) than group 2 animals (arterial shunt and venous shunt) suggests that venous ligation is associated with more intense ischemic histological findings than venous shunting.

Outcomes after External Iliac and Femoral Vascular Injuries

BACKGROUND

Vascular injuries occurring at the junction of the trunk and lower extremity are uncommon yet challenging because of their location and potential for associated truncal injuries. The purpose of this study was to examine and compare outcomes among patients sustaining external iliac and femoral vascular injuries.

METHODS

We performed a 13-year retrospective analysis of our level 1 trauma center database to identify and compare patients with external iliac and femoral vessel injuries. Multiple logistic regression analysis was performed to identify independent predictors for mortality.

RESULTS

During the study period, 135 patients with a median (interquartile range [IQR]) age of 25 (20-35) years were identified with external iliac (n = 29) and femoral vascular injuries (n = 106). The majority were male (85.9%) with a penetrating mechanism (84.5%), and the median (IQR) Injury Severity Score (ISS) was 16 (11-26). The overall mortality rate was 14.1%. In comparison with patients with femoral vascular injuries, patients with external iliac injuries presented with higher ISS (25 vs. 16, P < 0.001), lower Glasgow Coma Scale (14 vs. 15, P = 0.001) and had a higher incidence of mortality (41.4% vs. 6.6%, P < 0.001) and disability (13.8% vs. 1%, P = 0.007). Shunts were used in only 7 patients (5.2%). Stepwise logistic regression consistently identified external iliac injury (odds ratio, 15.6; 95% confidence interval, 1.72-141, P = 0.014 in best-fitted model) as independently associated with mortality.

CONCLUSIONS

In comparison with femoral vascular injuries, external iliac vascular injuries are associated with higher blood loss, more intense resuscitation, higher disability and mortality in patients sustaining junctional groin injuries. Early recognition and application of damage control techniques and resuscitative practices may result in improved outcomes.

Surgical management of a primary external iliac venous aneurysm causing pulmonary thromboembolism: report of a case

Primary iliac venous aneurysm is an extremely rare clinical entity. We report a case of primary external iliac venous aneurysm containing an intraluminal thrombus that caused pulmonary thromboembolism in a 22-year-old woman. The aneurysm and pulmonary emboli were detected during examination for sudden onset of dyspnea. After receiving anticoagulation and thrombolytic therapy, the patient underwent aneurysm resection. We devised venoplasty using a dual-row saphenous vein patch to cover the large defect of the vessel wall. Primary iliac venous aneurysms associated with pulmonary thromboembolism are uncommon and surgical repair is made difficult by the fragility of the affected vessel. We reviewed the clinical features of this unusual entity.