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Bakhshi K, Rhodes-Lyons H, Ahmed A. Rural Vascular Trauma: Time to Care. Am Surg 2024:31348241241684. [PMID: 38527493 DOI: 10.1177/00031348241241684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
Previous rural vascular trauma research has focused on case series dating back two decades. The current research aims to measure clinical decline in comparison to time to care in rural vascular trauma. This single-center retrospective cohort study included adult trauma patients with vascular injury who were admitted to a level II trauma center. Multivariable logistic regression assessed the effect of clinical decline based on arrival within the golden hour. 149 patients were included. For every 1 unit increase in the shock index ratio, there was 99.9% reduction in odds that the patient would arrive to the trauma center within the golden hour. This study is the first of its kind within the last two decades to comprehensively review rural vascular trauma. Our research showed clinical decline in SIR associated with prolonged time to care and will allow us to optimize pre-hospital care and transport in regions with prolonged arrival times.
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Affiliation(s)
- Kirran Bakhshi
- Department of General Surgery, Marshfield Clinic Health System, Marshfield, WI, USA
| | | | - Ayman Ahmed
- Department of Vascular Surgery, Marshfield Clinic Health System, Marshfield, WI, USA
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Boudreau S, Schucht J, Sigdel A, Dwivedi AJ, Wayne EJ. Contemporary Review of Traumatic Axillary and Subclavian Artery Injuries at an Urban Level One Trauma Center. Vasc Endovascular Surg 2024:15385744241230151. [PMID: 38284809 DOI: 10.1177/15385744241230151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
OBJECTIVE Traumatic axillary and subclavian artery injuries are uncommon. Limited data are available regarding patient and injury characteristics, as well as management strategies and outcomes. METHODS Retrospective chart review was performed on patients presenting to University of Louisville Hospital, an urban Level One Trauma Center, with traumatic axillary and subclavian artery injuries from 2015-2021. Patients were identified using University of Louisville trauma, radiology, and billing database searches based on ICD9/10 codes for axillary and subclavian artery injuries. Descriptive statistics are expressed as frequencies and percentages. Comparisons were performed using Fisher's Exact and Chi-squared tests. RESULTS Forty-four patients with traumatic axillary-subclavian arterial injuries were identified for analysis. Blunt and penetrating trauma were equally represented (n = 22 for both). A variety of injury types were seen, including minimal/intimal injury, laceration, pseudoaneurysm, transection, occlusion, and arteriovenous fistula. Management strategies were also variable, including non-operative, endovascular, planned hybrid, open, and endovascular converted to open. In operative patients, revascularization technical success was high (n = 31, 97%) with low likelihood of thrombosis (n = 2, 6%) and no infections. Among all patients, amputation rate was 5% (n = 2) and mortality rate was 9% (n = 3). Regarding arterial involvement, blunt injury was more likely to affect the subclavian (n = 18) than the axillary artery (n = 6) (P = .04). No significant difference was seen in brachial plexus injury based on artery involved (subclavian = 9 vs axillary = 11, P = .14) or mechanism (blunt = 6 vs penetrating = 11, P = .22). Non-operative management was more likely with subclavian artery injury (n = 11) vs axillary artery injury (n = 1) (P = .008). There was no significant difference between decision for non-operative (blunt = 9, penetrating = 3) vs operative (blunt = 13, penetrating = 19) management based on mechanism (P = .09). Transection injury was associated with an open repair strategy (endovascular/hybrid = 1, open/endovascular to open conversion = 11, P = .0003). Of the three patients requiring endovascular to open conversion, two required amputation, which were the only two patients in the study undergoing amputation. CONCLUSIONS Both open and endovascular/hybrid strategies are useful when treating traumatic axillary and subclavian artery injuries and are associated with high likelihood of revascularization technical success, with low rates of thrombosis or infection, when treated promptly at a trauma center with vascular specialists available. Transection injuries were most often treated with open revascularization. Patients undergoing amputation had blunt transection injuries to the subclavian artery and underwent endovascular to open conversion after failed attempts at endovascular revascularization.
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Affiliation(s)
- Sellers Boudreau
- Division of Vascular and Endovascular Surgery, Louisville, University of Louisville, Louisville, KY, USA
| | - Jessica Schucht
- Division of Vascular and Endovascular Surgery, Louisville, University of Louisville, Louisville, KY, USA
| | - Abindra Sigdel
- Division of Vascular and Endovascular Surgery, Louisville, University of Louisville, Louisville, KY, USA
| | - Amit J Dwivedi
- Division of Vascular and Endovascular Surgery, Louisville, University of Louisville, Louisville, KY, USA
| | - Erik J Wayne
- Division of Vascular and Endovascular Surgery, Louisville, University of Louisville, Louisville, KY, USA
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Spudil V, Hána L, Pohnán R. Peripheral vascular trauma - basic management, diagnosis and treatment. Rozhl Chir 2024; 102:315-320. [PMID: 38286678 DOI: 10.33699/pis.2023.102.8.315-320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2024]
Abstract
INTRODUCTION Peripheral vascular injuries occur in 1-3% of all traumas in civilian settings. The management of these injuries is often based on experience derived from war medicine where these injuries are more common. The goal of this article is to summarize basic guidelines for the diagnosis and treatment of vascular injuries. METHODS Western Trauma Association (WTA) and Eastern Association for the Surgery of Trauma (EAST) both have their own guidelines for vascular trauma management. RESULTS Vascular injuries occur both in penetrating and blunt traumas. Complete vessel disruption occurs more frequently in penetrating traumas. In the case of blunt trauma, intimal defects are more common, resulting in dissection, false aneurysm, or intramural hematoma. The limb is mostly endangered due to ischemia, reperfusion injury and the compartment syndrome. Prompt diagnosis and treatment are paramount. Vascular trauma management is part of the ATLS protocol and life-over-limb principle. The primary goal is to stop the massive external bleeding. Clinical examination and CT angiography are the most helpful for the diagnosis. Surgical revision is indicated when hard signs are present. This can be a damage control surgery with the primary goal to stop the bleeding as quickly as possible. A shunt can be used for temporary reperfusion of the limb. Definitive treatment can take the form of a simple suture, patches or graft interposition; both prosthetic and autologous grafts are used. Sufficient debridement and fasciotomy are important steps in the therapy. In some cases, endovascular treatment can be used. CONCLUSION Over the last century, the treatment strategy changed dramatically. Data from recent military conflicts show a decrease in amputation rates, and limb salvage has become a standard.
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Ardeshna S, Esposito E, Spalding C, Dunn J, Nahmias J, Grigorian A, Harmon L, Gergen A, Young A, Pascual J, Murry J, Ong A, Appelbaum R, Bugaev N, Tatar A, Zreik K, Scalea TM, Stein D, Lauerman M. Which Patients Receive Diagnostic Angiography? An EAST Multicenter Study Analysis of Internal Carotid Artery Blunt Cerebrovascular Injury. Am Surg 2023; 89:5183-5190. [PMID: 36417771 DOI: 10.1177/00031348221138083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
BACKGROUND Digital subtraction angiography (DSA) is the gold standard radiologic modality in blunt cerebrovascular injury (BCVI). However, computerized tomography angiography (CTA) is primarily used in modern practice with CTA's widespread availability and the decreased stroke rate with CTA use. The frequency and indications for DSA in BCVI is undefined. We hypothesized that DSA use in internal carotid artery (ICA) BCVI would be infrequent and dependent on radiologic features. METHODS This was a post hoc analysis of an EAST multicenter, prospective, observational trial of 16 trauma centers for stroke factors in BCVI. ICA BCVI was divided into those undergoing DSA and not undergoing DSA (no-DSA). Only ICA BCVI was included. RESULTS 332 ICA BCVI were included, 221 (66.6%) no-DSA and 111 (33.4%) DSA. Lower hospital trauma volume, non-urban environment, and non-academic status were associated with DSA use (all P ≤ .001). BCVI grade (P = .02) and presence of luminal stenosis (P = .005) were associated with DSA use while pseudoaneurysm presence was not. Median time to DSA was 1 hour. The most common indication for angiography was to determine the presence of injury in 71 (64%) ICA BCVI, followed by determining grade of injury in 16 (14.4%) and concerning imaging characteristics in 12 (10.8%). BCVI grade on initial imaging and on DSA were equivalent in 94 (84.7%) ICA BCVI. DISCUSSION DSA is frequently used in ICA BCVI, primarily early in the hospital course for injury diagnosis and grade determination. DSA appears primarily driven by hospital type, BCVI grade, and luminal stenosis.
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Affiliation(s)
| | | | | | - Julie Dunn
- University of Colorado-Anschutz Medical Campus, Aurora, CO, USA
| | | | | | | | - Anna Gergen
- University of Colorado Denver, Denver, CO, USA
| | - Andrew Young
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jose Pascual
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | | | - Rachel Appelbaum
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | | | - Antony Tatar
- Tufts University School of Medicine, Boston, MA, USA
| | | | | | - Deborah Stein
- R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
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Shaw J, Zakhary B, Coimbra R, Moore L, Scalea T, Kundi R, Teeter W, Romagnoli A, Moore E, Sauaia A, Dennis B, Brenner M. Use of Tranexamic Acid With Resuscitative Endovascular Balloon Occlusion of the Aorta is Associated With Higher Distal Embolism Rates: Results From the American Association of Surgery for Trauma Aortic Occlusion and Resuscitation for Trauma and Acute Care Surgery Trial. Am Surg 2023; 89:4208-4217. [PMID: 37431165 DOI: 10.1177/00031348231177918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2023]
Abstract
INTRODUCTION Tranexamic acid (TXA) use has been associated with thrombotic complications. OBJECTIVE We aim to investigate outcomes associated with TXA use in the setting of high- (HP) and low-profile (LP) introducer sheaths for resuscitative endovascular balloon occlusion of the aorta (REBOA). PARTICIPANTS The Aortic Occlusion and Resuscitation for Trauma and Acute Care Surgery (AORTA) database was queried for patients who underwent REBOA using a low-profile 7 French (LP) or high-profile, 11-14 French (HP) introducer sheaths between 2013 and 2022. Demographics, physiology, and outcomes were examined for patients who survived beyond the index operation. RESULTS 574 patients underwent REBOA (503 LP, 71 HP); 77% were male, mean age was 44 ± 19 and mean injury severity score (ISS) was 35 ± 16. 212 patients received TXA (181 [36%] LP, 31 [43.7%] HP). There were no significant differences in admission vital signs, GCS, age, ISS, SBP at AO, CPR at AO, and duration of AO among LP and HP patients. Overall, mortality was significantly higher in the HP (67.6%) vs the LP group (54.9%; P = .043). Distal embolism was significantly higher in the HP group (20.4%) vs the LP group (3.9%; P < .001). Logistic regression demonstrated that TXA use was associated with a higher rate of distal embolism in both groups (OR = 2.92; P = .021). 2 LP patients (one who received TXA) required an amputation. CONCLUSION Patients who undergo REBOA are profoundly injured and physiologically devastated. Tranexamic acid was associated with a higher rate of distal embolism in those who received REBOA, regardless of access sheath size. For patients receiving TXA, REBOA placement should be accompanied by strict protocols for immediate diagnosis and treatment of thrombotic complications.
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Affiliation(s)
| | - Bishoy Zakhary
- Riverside University Health System, Department of Surgery, 26520 Cactus Ave, Moreno Valley, CA 92555
| | - Raul Coimbra
- Riverside University Health System, Department of Surgery, 26520 Cactus Ave, Moreno Valley, CA 92555
| | - Laura Moore
- University of Texas Health Science Center at Houston (UTHealth), Department of Surgery, 6431 Fannin Street, Houston TX 77030
| | - Thomas Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201
| | - Rishi Kundi
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201
| | - William Teeter
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201
| | - Anna Romagnoli
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201
| | - Ernest Moore
- University of Colorado Anschutz Medical Campus, Department of Surgery, 12631 East 17th Avenue, Aurora, CO 80045
| | - Angela Sauaia
- University of Colorado Anschutz Medical Campus, Department of Surgery, 12631 East 17th Avenue, Aurora, CO 80045
| | - Bradley Dennis
- Vanderbilt University Medical Center, Division of Acute Care Surgery, 1161 21st,Avenue South, Medical Center North, D-5203, Nashville, TN 37232
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Stonko DP, Betzold RD, Azar FK, Edwards J, Abdou H, Elansary NN, Gerling KA, White J, Feliciano DV, DuBose JJ, Morrison JJ. Postoperative antiplatelet and/or anticoagulation use does not impact complication or reintervention rates after vein repair of arterial injury: A PROOVIT study. Vascular 2023; 31:777-783. [PMID: 35430941 DOI: 10.1177/17085381221082371] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
INTRODUCTION The use of antiplatelet (AP) and anticoagulation (AC) therapy after autogenous vein repair of traumatic arterial injury is controversial. The hypothesis in this study was that there is no difference in early postoperative outcomes regardless of whether AC, AP, both, or neither are used. METHODS The American Association for the Surgery of Trauma (AAST) PROspective Observational Vascular Injury Treatment (PROOVIT) registry was queried from November, 2013, to January, 2019, for arterial injuries repaired with a vein graft. Demographics and injury characteristics were compared. Need for in-hospital reoperation was the primary outcome in this four-arm study, assessed with two ordinal logistic regression models (1. no therapy vs. AC only vs. AC and AP; 2. no therapy vs. AP only vs. AC and AP). RESULTS 373 patients (52 no therapy, 88 AP only, 77 AC only, 156 both) from 19 centers with recorded Injury Severity Scores (ISS) were identified. Patients who received no therapy were younger than those who received AP (27.0 vs. 34.2, p = 0.02), had higher transfusion requirement (p < 0.01 between all groups) and a different distribution of anatomic injury (p < 0.01). After controlling for age, sex, ISS, platelet count, hemoglobin, pH, lactate, INR, transfusion requirement and anatomic location, there was no association with postoperative medical therapy and in-hospital operative reintervention, or any secondary outcome, including thrombosis (p = 0.67, p = 0.22). CONCLUSIONS Neither AC nor AP alone, nor in combination, impact complication rate after arterial repair with autologous vein. These patients can be safely treated with or without antithrombotics, recognizing that this study did not demonstrate a beneficial effect.
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Affiliation(s)
- David P Stonko
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Richard D Betzold
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Faris K Azar
- St Mary's Medical Center, West Palm Beach, Florida Atlantic University, Boca Raton, FL USA
| | - Joseph Edwards
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Hossam Abdou
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Noha N Elansary
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | | | - Joseph White
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - David V Feliciano
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Joseph J DuBose
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Jonathan J Morrison
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
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Magee GA, Dubose JJ, Inaba K, Lucero L, Dirks RC, O'Banion LA. Outcomes of vascular trauma associated with an evolution in the use of endovascular management. J Vasc Surg 2023:S0741-5214(23)00551-7. [PMID: 37023834 DOI: 10.1016/j.jvs.2023.02.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 01/05/2023] [Accepted: 02/04/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND The availability of endovascular techniques has led to a paradigm shift in the management of vascular injury. While previous reports showed trends towards the increased use of catheter-based techniques, there have been no contemporary studies of practice patterns and how these approaches differ by anatomic distributions of injury. The objective of this study is to provide a temporal assessment of the use of endovascular techniques in the management of torso, junctional (subclavian, axillary, iliac), and extremity injury and to evaluate any association with survival and length of stay. METHODS The American Association for the Surgery of Trauma (AAST) Prospective Observational Vascular Injury Treatment registry (PROOVIT) is the only large multicenter database focusing specifically on the management of vascular trauma. Patients in the AAST PROOVIT registry from 2013-2019 with arterial injuries were queried, and radial/ulnar, and tibial artery injuries were excluded. The primary aim was to evaluate the frequency in use of endovascular techniques over time and by body region. A secondary analysis evaluated the trends for junctional injuries and compared the mortality between those treated with open vs. endovascular repair. RESULTS Of the 3,249 patients included, 76% were male, and overall treatment type was 42% nonoperative, 44% open, 14% endovascular. Endovascular treatment increased an average of 2% per year from 2013-2019 (Range: 17-35%, R2 =.61). The use of endovascular techniques for junctional injuries increased by 5% per year (Range: 33%-63%, R2 =.89). Endovascular treatment was more common for thoracic, abdominal, and cerebrovascular injuries, and least likely in upper and lower extremity injuries. Injury severity score (ISS) was higher for patients receiving endovascular repair in every vascular bed except lower extremity. Endovascular repair was associated with significantly lower mortality than open repair for thoracic (5% vs. 46%, p<.001) and abdominal injuries (15% vs 38%, p<.001). For junctional injuries, endovascular repair was associated with a non-statistically significant lower mortality (19% vs. 29%, p=.099), despite higher ISS (25 vs. 21, p=.003) compared to open repair. CONCLUSION The reported use of endovascular techniques within the PROOVIT registry increased more than 10% over a 6-year period. This increase was associated with improved survival, especially for patients with junctional vascular injuries. Practices and training programs should account for these changes by providing access to endovascular technologies and instruction in the catheter-based skill sets to optimize outcomes in the future.
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Affiliation(s)
- Gregory A Magee
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA.
| | - Joseph J Dubose
- Division of Trauma and Acute Care Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Kenji Inaba
- Division of Trauma and Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD
| | - Leah Lucero
- Division of Vascular Surgery, Department of Surgery, University of California San Francisco-Fresno, Fresno, CA
| | - Rachel C Dirks
- Division of Vascular Surgery, Department of Surgery, University of California San Francisco-Fresno, Fresno, CA
| | - Leigh Ann O'Banion
- Division of Vascular Surgery, Department of Surgery, University of California San Francisco-Fresno, Fresno, CA
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Tung L, Seamon MJ, Dauer E, Alabi O, Benarroch-Gampel J, Passman J, Fitzgerald C, Lobichusky B, Mazzei M, Rodriguez W, Smith RN. Using Arterial Pressure Index to Predict Arterial Injuries in Penetrating Trauma to the Upper Extremities. Am Surg 2023; 89:108-112. [PMID: 33876999 DOI: 10.1177/00031348211011142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Upper extremity (UE) vascular injuries account for 18.4% of all traumatic vascular injuries. Arterial pressure index (API) use in lower extremity injuries to determine the need for further investigations is well established. However, due to collateral circulation in UEs, it is unclear if the same algorithm can be applied. The purpose of this study was to determine if APIs can be used to determine the need for computed tomography angiogram (CTA) in penetrating UE trauma. METHODS All adult trauma patients with penetrating UE trauma and APIs from 2006 to 2016 were identified at 3 urban US level 1 trauma centers. Sensitivity, specificity, and positive and negative predictive values of APIs <.9 in detecting UE arterial injuries were calculated. RESULTS During the 11-year study period, 218 patients met our inclusion criteria. Gunshot wounds comprised 76.6% and stab wounds 17.9%. Median injury severity score and API were 9 and 1, respectively. Seventy-two of our patients underwent evaluation with CTA. Of the injuries, the most common were thrombus or occlusion (46.7%), transection (23.1%), and dissection (15.4%), radiographically. Ultimately, 32 patients underwent surgical.
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Affiliation(s)
- Lily Tung
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, 14640University of Pennsylvania, Philadelphia, PA, USA
| | - Mark J Seamon
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, 14640University of Pennsylvania, Philadelphia, PA, USA
| | - Elizabeth Dauer
- Lewis Katz School of Medicine, 12314Temple University, Philadelphia, PA, USA
| | - Olamide Alabi
- 12239Emory University School of Medicine, Atlanta, GA, USA
| | | | - Jesse Passman
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, 14640University of Pennsylvania, Philadelphia, PA, USA
| | | | - Brone Lobichusky
- Lewis Katz School of Medicine, 12314Temple University, Philadelphia, PA, USA
| | - Michael Mazzei
- Lewis Katz School of Medicine, 12314Temple University, Philadelphia, PA, USA
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Stonko DP, Edwards J, Abdou H, Elansary NN, Lang E, Savidge SG, Hicks CW, Morrison JJ. The Underlying Cardiovascular Mechanisms of Resuscitation and Injury of REBOA and Partial REBOA. Front Physiol 2022; 13:871073. [PMID: 35615678 PMCID: PMC9125334 DOI: 10.3389/fphys.2022.871073] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 04/04/2022] [Indexed: 12/26/2022] Open
Abstract
Introduction: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is used for aortic control in hemorrhagic shock despite little quantification of its mechanism of resuscitation or cardiac injury. The goal of this study was to use pressure-volume (PV) loop analysis and direct coronary blood flow measurements to describe the physiologic changes associated with the clinical use of REBOA. Methods: Swine underwent surgical and vascular access to measure left ventricular PV loops and left coronary flow in hemorrhagic shock and subsequent placement of occlusive REBOA, partial REBOA, and no REBOA. PV loop characteristics and coronary flow are compared graphically with PV loops and coronary waveforms, and quantitatively with measures of the end systolic and end pressure volume relationship, and coronary flow parameters, with accounting for multiple comparisons. Results: Hemorrhagic shock was induced in five male swine (mean 53.6 ± 3.6 kg) as demonstrated by reduction of stroke work (baseline: 3.1 vs. shock: 1.2 L*mmHg, p < 0.01) and end systolic pressure (ESP; 109.8 vs. 59.6 mmHg, p < 0.01). ESP increased with full REBOA (178.4 mmHg; p < 0.01), but only moderately with partial REBOA (103.0 mmHg, p < 0.01 compared to shock). End systolic elastance was augmented from baseline to shock (1.01 vs. 0.39 ml/mmHg, p < 0.01) as well as shock compared to REBOA (4.50 ml/mmHg, p < 0.01) and partial REBOA (3.22 ml/mmHg, p = 0.01). Percent time in antegrade coronary flow decreased in shock (94%-71.8%, p < 0.01) but was rescued with REBOA. Peak flow increased with REBOA (271 vs. shock: 93 ml/min, p < 0.01) as did total flow (peak: 2136, baseline: 424 ml/min, p < 0.01). REBOA did not augment the end diastolic pressure volume relationship. Conclusion: REBOA increases afterload to facilitate resuscitation, but the penalty is supraphysiologic coronary flows and imposed increase in LV contractility to maintain cardiac output. Partial REBOA balances the increased afterload with improved aortic system compliance to prevent injury.
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Affiliation(s)
- David P. Stonko
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, United States,Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Joseph Edwards
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, United States
| | - Hossam Abdou
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, United States
| | - Noha N. Elansary
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, United States
| | - Eric Lang
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, United States
| | - Samuel G. Savidge
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, United States
| | - Caitlin W. Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jonathan J. Morrison
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, United States,*Correspondence:Jonathan J. Morrison,
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Legare T, Schroll R, Hunt JP, Duchesne J, Marr A, Schoen J, Greiffenstein P, Stuke L, Smith A. Prehospital Tourniquets Placed on Limbs Without Major Vascular Injuries, has the Pendulum Swung Too far? Am Surg 2022; 88:2103-2107. [PMID: 35435022 DOI: 10.1177/00031348221088968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Combat applications of tourniquets for extremity trauma have led to increased civilian prehospital tourniquet use. Studies have demonstrated that appropriate prehospital tourniquet application can decrease the incidence of arrival in shock without increasing limb complications. The aim of this study was to examine outcomes of prehospital tourniquet placement without definitive vascular injury. METHODS Retrospective review was performed of a prospectively maintained database by the American Association for the Surgery of Trauma from 29 trauma centers. Patients in this subset analysis did not have a significant vascular injury as determined by imaging or intra-operatively. Patients who received prehospital tourniquets (PHTQ) were compared to patients without prehospital tourniquets (No-PHTQ). Outcomes were amputation rates, nerve palsy, compartment syndrome, and in-hospital mortality. RESULTS A total of 622 patients had no major vascular injury. The incidence of patients without major vascular injury was higher in the PHTQ group (n = 585/962, 60.8 vs n = 37/88, 42.0%, P < .001). Cohorts were similar in age, gender, penetrating mechanism, injury severity scores (ISS), abbreviated injury score (AIS), and mortality (P > .05). Amputation rates were 8.3% (n = 49/585) in the PHTQ group compared to 0% (n = 0/37) in the No-PHTQ group. Amputation rates were higher in PHTQ than No-PHTQ with similar ISS and AIS (P = .96, P = .59). The incidence of nerve palsy and compartment syndrome was not different (P > .05). CONCLUSIONS This study showed a significant amount of prehospital tourniquets are being placed on patients without vascular injuries. Further studies are needed to elucidate the appropriateness of prehospital tourniquets, including targeted education of tourniquet placement.
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Affiliation(s)
- Timothy Legare
- Department of Surgery, 12258Louisiana State University Health Science Center, New Orleans, LA, USA
| | - Rebecca Schroll
- Department of Surgery, 12255Tulane University School of Medicine, New Orleans, LA, USA
| | - John P Hunt
- Department of Surgery, 12258Louisiana State University Health Science Center, New Orleans, LA, USA.,University Medical Center, New Orleans, LA, USA
| | - Juan Duchesne
- Department of Surgery, 12255Tulane University School of Medicine, New Orleans, LA, USA.,University Medical Center, New Orleans, LA, USA
| | - Alan Marr
- Department of Surgery, 12258Louisiana State University Health Science Center, New Orleans, LA, USA.,University Medical Center, New Orleans, LA, USA
| | - Jonathan Schoen
- Department of Surgery, 12258Louisiana State University Health Science Center, New Orleans, LA, USA.,University Medical Center, New Orleans, LA, USA
| | - Patrick Greiffenstein
- Department of Surgery, 12258Louisiana State University Health Science Center, New Orleans, LA, USA.,University Medical Center, New Orleans, LA, USA
| | - Lance Stuke
- Department of Surgery, 12258Louisiana State University Health Science Center, New Orleans, LA, USA.,University Medical Center, New Orleans, LA, USA
| | - Alison Smith
- Department of Surgery, 12258Louisiana State University Health Science Center, New Orleans, LA, USA.,University Medical Center, New Orleans, LA, USA
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11
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Melmer PD, Clatterbuck B, Parker V, Castater CA, Klingensmith NJ, Ramos CR, Busby S, Hurst SD, Koganti D, Williams KN, Grant AA, Smith RN, Benarroch-Gampel J, Dente CJ, Rajani RR, Todd SR, Sciarretta JD. Superior Mesenteric Artery and Vein Injuries: Operative Strategies and Outcomes. Vasc Endovascular Surg 2021; 56:40-48. [PMID: 34533371 DOI: 10.1177/15385744211042491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Traumatic injuries to the mesenteric vessels are rare and often lethal. Visceral vessels, such as the superior mesenteric artery (SMA) and vein (SMV), supply blood to the small and large bowel by a rich system of collaterals. Because fewer than 100 such injuries have been described in the literature, they pose challenges in both diagnosis and management and can unfortunately result in high mortality rates. Prompt diagnosis, surgical intervention, and resuscitation can lead to improved outcomes. Here, we review the literature surrounding traumatic injuries of the SMA/SMV and discuss management strategies.
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Affiliation(s)
- Patrick D Melmer
- Grand Strand Medical Center, University of South Carolina, Myrtle Beach, SC, USA
| | - Brant Clatterbuck
- Emory University School of Medicine, Marcus Trauma Center, 71741Grady Memorial Hospital, Atlanta, GA, USA
| | | | - Christine A Castater
- Emory University School of Medicine, Marcus Trauma Center, 71741Grady Memorial Hospital, Atlanta, GA, USA
| | - Nathan J Klingensmith
- Emory University School of Medicine, Marcus Trauma Center, 71741Grady Memorial Hospital, Atlanta, GA, USA
| | - Christopher R Ramos
- Emory University School of Medicine, Marcus Trauma Center, 71741Grady Memorial Hospital, Atlanta, GA, USA
| | - Stephanie Busby
- Emory University School of Medicine, Marcus Trauma Center, 71741Grady Memorial Hospital, Atlanta, GA, USA
| | - Stuart D Hurst
- Emory University School of Medicine, Marcus Trauma Center, 71741Grady Memorial Hospital, Atlanta, GA, USA
| | - Deepika Koganti
- Emory University School of Medicine, Marcus Trauma Center, 71741Grady Memorial Hospital, Atlanta, GA, USA
| | - Keneesha N Williams
- Emory University School of Medicine, Marcus Trauma Center, 71741Grady Memorial Hospital, Atlanta, GA, USA
| | - April A Grant
- Emory University School of Medicine, Marcus Trauma Center, 71741Grady Memorial Hospital, Atlanta, GA, USA
| | - Randi N Smith
- Emory University School of Medicine, Marcus Trauma Center, 71741Grady Memorial Hospital, Atlanta, GA, USA
| | - Jaime Benarroch-Gampel
- Emory University School of Medicine, Marcus Trauma Center, 71741Grady Memorial Hospital, Atlanta, GA, USA
| | - Christopher J Dente
- Emory University School of Medicine, Marcus Trauma Center, 71741Grady Memorial Hospital, Atlanta, GA, USA
| | - Ravi R Rajani
- Emory University School of Medicine, Marcus Trauma Center, 71741Grady Memorial Hospital, Atlanta, GA, USA
| | - Samual R Todd
- Emory University School of Medicine, Marcus Trauma Center, 71741Grady Memorial Hospital, Atlanta, GA, USA
| | - Jason D Sciarretta
- Emory University School of Medicine, Marcus Trauma Center, 71741Grady Memorial Hospital, Atlanta, GA, USA
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12
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Stonko DP, Azar FK, Betzold RD, Morrison JJ, Fransman RB, Holcomb J, Bee T, Fabian TC, Skarupa DJ, Stein DM, Kozar RA, O'Connor JV, Scalea TM, DuBose JJ, Feliciano DV. Contemporary Management and Outcomes of Injuries to the Inferior Vena Cava: A Prospective Multicenter Trial From PROspective Observational Vascular Injury Treatment. Am Surg 2021:31348211038556. [PMID: 34384266 DOI: 10.1177/00031348211038556] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Injuries to the inferior vena cava (IVC), while uncommon, have a high mortality despite modern advances. The goal of this study is to describe the diagnosis and management in the largest available prospective data set of vascular injuries across anatomic levels of IVC injury. METHODS The American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment (PROOVIT) registry was queried from November 2013 to January 2019. Demographics, diagnostic modalities, injury patterns, and management strategies were recorded and analyzed. Comparisons between anatomic levels were made using non-parametric Wilcoxon rank-sum statistics. RESULTS 140 patients from 19 institutions were identified; median age was 30 years old (IQR 23-41), 75% were male, and 62% had penetrating mechanism. The suprarenal IVC group was associated with blunt mechanism (53% vs 32%, P = .02), had lower admission systolic blood pressure, pH, Glasgow Coma Scale (GCS), and higher ISS and thorax and abdomen AIS than the infrarenal injury group. Injuries were managed with open repair (70%) and ligation (30% overall; infrarenal 37% vs suprarenal 13%, P = .01). Endovascular therapy was used in 2% of cases. Overall mortality was 42% (infrarenal 33% vs suprarenal 66%, P<.001). Among survivors, there was no difference in first 24-hour PRBC transfusion requirement, or hospital or ICU length of stay. CONCLUSIONS Current PROOVIT registry data demonstrate continued use of ligation extending to the suprarenal IVC, limited adoption of endovascular management, and no dramatic increase in overall survival compared to previously published studies. Survival is likely related to IVC injury location and total injury burden.
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Affiliation(s)
- David P Stonko
- Department of Surgery, 588543The Johns Hopkins Hospital, Baltimore, MD, USA.,137889R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - Faris K Azar
- St Mary's Medical Center, West Palm Beach, FL, USA; 1782Florida Atlantic University, Boca Raton, FL, USA
| | - Richard D Betzold
- 137889R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - Jonathan J Morrison
- 137889R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - Ryan B Fransman
- Department of Surgery, 588543The Johns Hopkins Hospital, Baltimore, MD, USA
| | - John Holcomb
- The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Tiffany Bee
- University of Tennessee Health Science Center, Memphis, TN, USA
| | | | | | - Deborah M Stein
- 137889R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA.,University of California, San Francisco, CA, USA
| | - Rosemary A Kozar
- 137889R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - James V O'Connor
- 137889R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - Thomas M Scalea
- 137889R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - Joseph J DuBose
- 137889R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - David V Feliciano
- 137889R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
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13
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de Figueirêdo BL, Monteiro Rabêlo PJ, da Silva AP, Rafael Moutinho LE, Lucena da Fonseca Neto OC. Multiple sites bullet embolism as a cause of acute abdomen. Turk J Emerg Med 2021; 21:125-128. [PMID: 34377870 PMCID: PMC8330603 DOI: 10.4103/2452-2473.320804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 02/18/2021] [Accepted: 02/22/2021] [Indexed: 11/04/2022] Open
Abstract
Bullet embolism (BE) is a rare and misdiagnosed phenomenon that can significantly affect the cardiovascular system. It occurs when a bullet enters and migrates through the body vessels in gunshot victims. We report in this article a case of a 25-year-old male patient, victim of penetrating trauma caused by a firearm projectile that presented two embolism destinations with acute ischemic repercussions: the right brachial artery and the branches of the superior mesenteric artery. We quickly performed surgical exploration to assess the level of ischemia and resect the foreign body. To the best of the authors' knowledge, this is the only case of acute vascular abdomen due to BE in the literature. There is no standard treatment for BE, and each case should be studied according to signs and symptoms while considering the risks of the destination vessel for the victim. Imaging is necessary for early diagnosis, and the medical team must be aware of multiple and extraordinary critical ischemia presentations when bullet trajectory suggests embolism.
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14
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Kaygin MA, Halici U. Our clinical experiences of vascular injuries due to lumbar disc surgeries. Vascular 2021; 30:555-558. [PMID: 34102928 DOI: 10.1177/17085381211021671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES We aimed to evaluate emergency vascular complications of the lumbar disc reconstructive surgery in this study. METHOD Between March 2006 and February 2020, nine patients (six males and three females; mean age: 53.4 ± 9.6 years; range: 38-64 years) who underwent emergent vascular intervention during lumbar spinal disc reconstructive surgery in our clinic were included in this retrospective study. RESULT The left common iliac artery injury, the left common iliac artery and left common iliac vein injuries, bilateral common iliac artery and abdominal aortic injuries, and vena cava inferior injury with left common iliac vein and right common iliac vein injuries were detected in two, three, two, and two patients, respectively. In addition, 16 mm Dacron tube graft interposition and graft patch plasty were performed in one and two patients who had an abdominal aortic injury, respectively. Also, 8 mm polytetrafluoroethylene straight graft interposition was performed in two patients with left common iliac artery injury, and lateral wall repair was performed in other patients. Graft patch plasty and 8 mm polytetrafluoroethylene graft interposition were performed in one patient with vena cava inferior injury and left common iliac vein injury, respectively. Also, lateral wall repair was performed in other patients with venous injuries. Deep venous thrombosis had developed in three patients, and one patient of these had a pulmonary embolism. CONCLUSION The incidence of vascular injury after the lumbar disc surgery is relatively low; however, the emergency vascular operation should be performed as soon as possible.
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Affiliation(s)
- Mehmet Ali Kaygin
- Cardiovascular Surgery Department, Erzurum Regional Training and Research Hospital, University of Health Sciences, Erzurum, Turkey
| | - Umit Halici
- Cardiovascular Surgery Department, Samsun Training and Research Hospital, University of Health Sciences, Samsun, Turkey
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15
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Abdou H, Du J, Harfouche MN, Patel N, Edwards J, Richmond M, Elansary N, Morrison JJ. Development of an Endovascular Model of Pelvic Hemorrhage Using Volumetric Computed Tomography Validation. J Endovasc Ther 2021; 28:614-622. [PMID: 34018880 DOI: 10.1177/15266028211016422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Uncontrolled pelvic hemorrhage from trauma is associated with mortality rates above 30%. The ability of an intervention to reduce blood loss from pelvic trauma is paramount to its success. The objective of this study was to determine if computed tomography volumetric analysis could be used to quantify blood loss in a porcine endovascular pelvic hemorrhage model. MATERIALS AND METHODS Yorkshire swine under general anesthesia underwent balloon dilation and rupture of the profunda femoris artery, which was confirmed by digital subtraction angiography. Computed tomography angiography and postprocessing segmentation were performed to quantify pelvic hemorrhage volume at 5 and 30 minutes after injury. Continuous hemodynamic and iliofemoral flow data were obtained. Baseline and postinjury hemoglobin, hematocrit and lactate were collected. RESULTS Of 6 animals enrolled, 5 survived the 30-minute post-injury period. One animal died at 15 minutes. Median volume of pelvic hemorrhage was 141±106 cm3 at 5 minutes and 302±79 cm3 at 30 minutes with a 114% median increase in hematoma volume over 25 minutes (p=0.040). There was a significant decrease in mean arterial pressure (107 to 71 mm Hg, p=0.030) and iliofemoral flow (561 to 122 mL/min, p=0.014) at 30 minutes postinjury, but no significant changes in hemoglobin, hematocrit, or heart rate. CONCLUSION Computed tomography volumetric analysis can be used to quantify rate and volume of blood loss in a porcine endovascular pelvic hemorrhage model. Future studies can incorporate this approach when evaluating the effect of hemorrhage control interventions associated with pelvic fractures.
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Affiliation(s)
- Hossam Abdou
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - Jonathan Du
- Georgetown University School of Medicine, Washington, DC, USA
| | - Melike N Harfouche
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - Neerav Patel
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - Joseph Edwards
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - Michael Richmond
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - Noha Elansary
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - Jonathan J Morrison
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
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16
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Sheets NW, Roderick O, Plurad DS. Common Iliac Vein Injury in Blunt Abdominal Trauma Without Pelvic Fractures. Cureus 2021; 13:e14401. [PMID: 33987054 PMCID: PMC8110284 DOI: 10.7759/cureus.14401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Iliac vein injury in the absence of pelvic fractures is rare. We present the case of a 27-year-old male involved in a motorcycle crash. Imaging demonstrated a lumbar hernia and pelvic hematoma in the absence of pelvic fractures. The patient became unstable and required emergency surgery demonstrating an iliac vein injury requiring ligation. Diagnosis and management of this rare injury is reviewed.
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Affiliation(s)
- Nicholas W Sheets
- Trauma and Acute Care Surgery, Riverside Community Hospital, Riverside, USA
| | - Olivas Roderick
- General Surgery, Riverside Community Hospital, Riverside, USA
| | - David S Plurad
- Trauma and Acute Care Surgery, Riverside Community Hospital, Riverside, USA
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17
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Pereira-Neves A, Gouveia R, Dias-Neto M, Duarte-Gamas L, Rocha-Neves J, Teixeira J. Covered Endovascular Repair of Innominate Artery Bifurcation After Thoracic Blunt Trauma. Vasc Endovascular Surg 2020; 55:405-409. [PMID: 33252013 DOI: 10.1177/1538574420976478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Innominate artery (IA) injury is a rare entity with most patients dying before reaching the hospital. While open surgery remains the standard treatment, the endovascular approach is attractive as it may reduce perioperative morbidity and mortality. We report a case of IA blunt injury extending to the subclavian artery with pseudoaneurysm formation successfully treated with covered stenting of IA and its bifurcation. A 49-year-old male was admitted after suffering multiple trauma due to a high energy impact motorcycle crash. In the emergency room, the patient was hypotensive with a Glasgow coma score of 15. On physical examination, he had right peri-orbital ecchymosis, left otorrhagia and an open patella fracture. The computed tomographic angiography (CTA) revealed enlargement of the mediastinum and a 29 mm pseudoaneurysm involving the right brachiocephalic trunk and its bifurcation. Under general anesthesia, a covered balloon-expandable stent (CBES) was then placed in the IA followed by kissing stent of its bifurcation with an additional 2 covered balloon-expandable stents. Final subtraction angiography demonstrated complete pseudoaneurysm exclusion and stent patency without additional complications. No neurologic deficits or other intervention-related complications were found in the postoperative period. At 10 months follow-up, the patient remained asymptomatic and with palpable distal pulses. Endovascular management of IA injury may provide a good alternative to open surgery with low perioperative morbidity and mortality.
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Affiliation(s)
- António Pereira-Neves
- Department of Biomedicine-Unit of Anatomy, 26705Faculty of Medicine, University of Porto, Portugal.,Department of Surgery and Physiology, 26705Faculty of Medicine, University of Porto, Portugal.,Department of Angiology and Vascular Surgery, 26706Centro Hospitalar Universitário São João, EPE, Porto, Portugal
| | - Ricardo Gouveia
- Department of Surgery and Physiology, 26705Faculty of Medicine, University of Porto, Portugal.,Department of Angiology and Vascular Surgery, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Marina Dias-Neto
- Department of Surgery and Physiology, 26705Faculty of Medicine, University of Porto, Portugal.,Department of Angiology and Vascular Surgery, 26706Centro Hospitalar Universitário São João, EPE, Porto, Portugal.,Cardiovascular R&D Unit, 26705Faculdade de Medicina da Universidade Do Porto, Portugal
| | - Luís Duarte-Gamas
- Department of Surgery and Physiology, 26705Faculty of Medicine, University of Porto, Portugal.,Department of Angiology and Vascular Surgery, 26706Centro Hospitalar Universitário São João, EPE, Porto, Portugal
| | - João Rocha-Neves
- Department of Biomedicine-Unit of Anatomy, 26705Faculty of Medicine, University of Porto, Portugal.,Department of Surgery and Physiology, 26705Faculty of Medicine, University of Porto, Portugal.,Department of Angiology and Vascular Surgery, 26706Centro Hospitalar Universitário São João, EPE, Porto, Portugal
| | - José Teixeira
- Department of Angiology and Vascular Surgery, 26706Centro Hospitalar Universitário São João, EPE, Porto, Portugal
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18
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Farhat-Sabet A, Lauerman M, Chavez A, Lloyd J, Scalea T, Stein D. Blunt Cerebrovascular Injury Screening Criteria Should Include Motor Vehicle Crash Characteristics. Am Surg 2020; 87:390-395. [PMID: 32993322 DOI: 10.1177/0003134820951475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Current screening criteria miss 30% of blunt cerebrovascular injuries (BCVIs). Motor vehicle collisions (MVCs) are the leading BCVI mechanism, and delineating MVC characteristics associated with BCVI formation may augment current screening criteria. METHODS We retrospectively identified BCVI Denver injury screening criteria as able from the Crash Injury Research and Engineering Network (CIREN) database. Severe MVC markers were considered: mean change in velocity (delta-v) greater than 40 km/hour, steering wheel airbag deployment, ejection, or rollover. RESULTS 93 BCVIs were included. Injury screening criteria were not present in 37/93 (39.8%) BCVIs. Vertebral BCVI more often had injury screening criteria than internal carotid BCVIs (73.2% vs 26.8%, P = .001). There was a significant difference in delta-v (30.78 km/hour vs 51.00 km/hour, P < .001) between BCVI with and without injury screening criteria. BCVI without injury screening criteria more often had safety device use through seatbelt position snug across the hips (94.6% vs 74.5%, P = .01) and pretensioner deployment (92.6% vs 70.2%, P = .04). Examining only drivers, BCVI without injury screening criteria more often had steering wheel airbag deployment (89.7% vs 68.9%, P = .05). Markers of severe MVC were seen in 36/37 (97.3%) BCVIs without injury screening criteria. DISCUSSION BCVI without injury screening criteria occurred during higher deceleration MVCs with more frequent/appropriate safety device use, suggesting crash deceleration as a mechanism of BCVI formation. Expanding BCVI screening criteria to encompass severe MVCs may lessen the number of BCVI missed.
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Affiliation(s)
- Ashley Farhat-Sabet
- Division of Trauma/Critical Care, University of Maryland, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Margaret Lauerman
- Division of Trauma/Critical Care, University of Maryland, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Alicia Chavez
- Division of Trauma/Critical Care, University of Maryland, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Joe Lloyd
- Division of Trauma/Critical Care, University of Maryland, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Thomas Scalea
- Division of Trauma/Critical Care, University of Maryland, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Deborah Stein
- Department of Surgery, University of California, San Francisco, CA, USA
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19
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Sheehan BM, Grigorian A, Maithel S, Borazjani B, Fujitani RM, Kabutey NK, Lekawa M, Nahmias J. Penetrating Abdominal Aortic Injury: Comparison of ACS-Verified Level-I and II Trauma Centers. Vasc Endovascular Surg 2020; 54:692-696. [PMID: 32787694 DOI: 10.1177/1538574420947234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Penetrating abdominal aortic injury (PAAI) is a highly acute injury requiring prompt surgical management. When compared to surgeons at level-II trauma centers, surgeons at level-I trauma centers are more likely to take in-house call, and may more often be available within 15 minutes of patient arrival. Thus, we hypothesized that level-I trauma centers would have a lower mortality rate than level-II trauma centers in patients with PAAI. METHODS We queried the Trauma Quality Improvement Program database for patients with PAAI, and compared patients treated at American College of Surgeons (ACS)-verified level-I centers to those treated at ACS level-II centers. RESULTS PAAI was identified in 292 patients treated at level-I centers and 86 patients treated at level-II centers. Patients treated at the 2 center types had similar median age, injury severity scores and prevalence of diabetes, hypertension, and smoking (p > 0.05). There was no difference in the frequency of additional intra-abdominal vascular injuries (p > 0.05). Median time to hemorrhage control (level-I: 40.8 vs level-II: 49.2 minutes, p = 0.21) was similar between hospitals at the 2 trauma center levels. We found no difference in the total hospital length of stay or post-operative complications (p > 0.05). When controlling for covariates, we found no difference in the risk of mortality between ACS verified level-I and level-II trauma centers (OR:1.01, CI:0.28-2.64, p = 0.99). CONCLUSION Though the majority of PAAIs are treated at level-I trauma centers, we found no difference in the time to hemorrhage control, or the risk of mortality in those treated at level-I centers when compared to those treated at level-II trauma centers. This finding reinforces the ACS-verification process, which strives to achieve similar outcomes between level-I and level-II centers.
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Affiliation(s)
- Brian Matthew Sheehan
- Department of Surgery, 8788University of California, Irvine School of Medicine, CA, USA
| | - Areg Grigorian
- Department of Surgery, 8788University of California, Irvine School of Medicine, CA, USA
| | - Shelley Maithel
- Department of Surgery, 8788University of California, Irvine School of Medicine, CA, USA
| | - Boris Borazjani
- Department of Surgery, 8788University of California, Irvine School of Medicine, CA, USA
| | - Roy M Fujitani
- Department of Surgery, 8788University of California, Irvine School of Medicine, CA, USA
| | - Nii-Kabu Kabutey
- Department of Surgery, 8788University of California, Irvine School of Medicine, CA, USA
| | - Michael Lekawa
- Department of Surgery, 8788University of California, Irvine School of Medicine, CA, USA
| | - Jeffry Nahmias
- Department of Surgery, 8788University of California, Irvine School of Medicine, CA, USA
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20
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Ang ZH, Brown K, Rice M, Fisher D. Role of rural general surgeons in managing vascular surgical emergencies. ANZ J Surg 2020; 90:1364-1368. [PMID: 32558132 DOI: 10.1111/ans.16068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 05/05/2020] [Accepted: 05/17/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND A rural general surgeon has historically been required to perform a wide variety of subspecialist procedures. Increasingly sub-specialized training programs have restricted younger surgeons' experience in the general surgery-associated subspecialties. Time critical vascular surgical emergencies are frequently encountered by rural general surgeons. This study aims to audit the prevalence of vascular surgical emergencies at a geographically remote regional centre and define the role of the general surgeon in managing these patients. METHODS A single-centre, retrospective study was performed to analyse the outcomes of the patients who presented to Dubbo Base Hospital with an emergency vascular pathology or developed such a condition during admission, between October 2010 and June 2019. Patients were identified by relevant International classification of diseases (ICD) (10th revision) diagnostic codes for vascular emergencies. Acute complications following surgery for haemodialysis access were excluded. RESULTS A total of 134 patients were identified during the study period and the majority were transferred to a tertiary centre for surgical intervention. Sixteen patients underwent emergency vascular surgery locally due to concerns about potential loss of life or limb if intervention was delayed by transfer; 69% of patients who underwent surgery locally survived with limb salvation. CONCLUSION While most patients can safely be transferred to a tertiary centre, some require surgery locally in order to maximize chance of life or limb preservation. There is a strong argument for exposure of general surgical trainees with an interest in rural surgery to vascular surgery and other subspecialties.
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Affiliation(s)
- Zhen H Ang
- Department of Surgery, Dubbo Base Hospital, Dubbo, New South Wales, Australia.,Prince of Wales Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Kilian Brown
- Department of Surgery, Dubbo Base Hospital, Dubbo, New South Wales, Australia.,Surgical Outcomes Research Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Mark Rice
- Department of Surgery, Dubbo Base Hospital, Dubbo, New South Wales, Australia
| | - Dean Fisher
- Department of Surgery, Dubbo Base Hospital, Dubbo, New South Wales, Australia
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21
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Abstract
Background Vascular diseases are evolving fast in sub-Saharan Africa, but its management is challenged by lack of expertise and infrastructure. In the light of the prevailing challenge, this study was done to see the pattern of vascular disease and its treatment in a tertiary referral hospital. Methods A prospective cross-sectional study was done over a period of one year (February 9, 2016 to February 8, 2017) at Tikur Anbessa specialized hospital (TASH) at Addis Ababa, Ethiopia. Results A total of 386 patients were seen at the surgical OPD. Of these, 78(20.2%) were admitted and operate on. The male to female ratio was 1.3:1. The mean age affected was 39 +/- 10 (Range 12–91 years). On the other hand, 132 (34.2%) patients came with PAD. Of them, 46(34.8%) presented with either frank Gangrene or pre-gangrene stage. The rest 86(65.1%) had claudication pain. The other diseases seen are Varicose Vein, 100(25.9%), Carotid body tumors, 60(15.4%), Aneurysmal diseases, 36(9.1%), Vascular malformations, 34(8.7%), and Vascular injuries, 22(5.6%). During the study period, 28(35.9%) PAD, 22(28.2%) trauma patients, 8(10.2%) Chemodectomas, 8(10.2%) aneurysms, 6(7.7%) hemangiomas, 4(5.1%) varicose vein and 2(2.6%) AV fistula patients were operated. Conclusion The pattern of vascular disease in Ethiopia is becoming a challenge. The gap created due to limited vascular surgeons, poor infrastructure and absent supply chain system has significantly compromised the number and type of operated-on patients. These challenges result in preventable morbidity and mortality.
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Affiliation(s)
- Nebyou Seyoum
- Cardiothoracic and Vascular Unit, Department of Surgery, School of Medicine, College of Health Sciences, Addis Ababa University, Ethiopia
| | - Dawit G/Giorgis
- Cardiothoracic and Vascular Unit, Department of Surgery, School of Medicine, College of Health Sciences, Addis Ababa University, Ethiopia
| | - Berhanu Nega
- Cardiothoracic and Vascular Unit, Department of Surgery, School of Medicine, College of Health Sciences, Addis Ababa University, Ethiopia
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Abstract
Objectives: Widespread availability of computed tomography angiography (CTA) for diagnosing arterial injury in injured extremities has created the possibility of overuse. The objective of this study was to evaluate CTA utilization, indications, ordering personnel, and rate of significant findings for blunt or penetrating extremity trauma at a level I trauma center. Methods: We performed a retrospective chart review of 1440 consecutive CTAs of upper and lower extremities from 2010 to 2012 at a large level I trauma center, and included only those done for acute trauma. Data were collected with regard to injury, initial exam, reason given for ordering a CTA, specialty of physician ordering CTA, results, and vascular interventions needed. CTAs were categorized as appropriately ordered based on if there was a documented abnormal distal pulse or ankle-brachial index (ABI). Study indication was classified as inconclusive if no vascular exam was documented or physical exam varied. Results: A total of 481 CTAs were performed after blunt or penetrating trauma in the emergency room with 31.0% appropriately indicated, 48.0% without indication, and 21.8% inconclusive. Mechanism of injury was most commonly a gunshot wound (40.3%), followed by motor vehicle accidents (39.5%). Overall, 61.5% of the studies had normal arterial flow and only 15.8% of CTAs required vascular operative intervention. Of the studies appropriately indicated, 76.5% had positive findings, with 43% needing operative intervention compared to the inappropriately indicated studies only 11.6% had positive findings, with 0.4% needing operative intervention (P < .0001). Conclusion: CTA for blunt or penetrating trauma at a level I trauma center may be over-utilized. Often, this advanced imaging is ordered prior to orthopaedic evaluation or limb reduction, without exam-based indication, and most do not affect patients’ treatment. From our study, CTA utilization based on more stringent exam findings at our hospital could eliminate 48% of all CTA studies for trauma.
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23
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Abstract
Hypothenar or thenar hammer syndrome (HHS) and hand-arm vibration syndrome (HAVS) are diseases caused by acute or chronic trauma to the upper extremities. Since both diseases are generally related to occupation and are recognised as occupational diseases in most countries, vascular physicians need to be able to distinguish between the two entities and differentiate them from other diagnoses. A total of 867 articles were identified as part of an Internet search on PubMed and in non-listed occupational journals. For the analysis we included 119 entries on HHS as well as 101 papers on HAVS. A professional history and a job analysis were key components when surveying the patient's medical history. The Doppler-Allen test, duplex sonography and optical acral pulse oscillometry were suitable for finding an objective basis for the clinical tests. In the case of HHS, digital subtraction angiography was used to confirm the diagnosis and plan treatment. Radiological tomographic techniques provided very limited information distal to the wrist. The vascular component of HAVS proved to be strongly dependent on temperature and had to be differentiated from the various other causes of secondary Raynaud's phenomenon. The disease was medicated with anticoagulants and vasoactive substances. If these were not effective, a bypass was performed in addition to various endovascular interventions, especially in the case of HHS. Despite the relatively large number of people exposed, trauma-induced circulatory disorders of the hands can be observed in a comparatively small number of cases. For the diagnosis of HHS, the morphological detection of vascular lesions through imaging is essential since the disorder can be accompanied by critical limb ischaemia, which may require bypass surgery. In the case of HAVS, vascular and sensoneurological pathologies must be objectified through provocation tests. The main therapeutic approach to HAVS is preventing exposure.
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Affiliation(s)
- Uwe Wahl
- 1 BG Hospital Bergmannstrost Halle, Department of Internal Medicine, Halle, Germany
| | - Ingmar Kaden
- 2 BG Hospital Bergmannstrost Halle, Department of Diagnostic Imaging and Interventional Radiology, Halle, Germany
| | - Andreas Köhler
- 3 Practice for Cardiology and Vascular Diseases, Halle, Germany
| | - Tobias Hirsch
- 4 Practice for Internal Medicine and Vascular Diseases, Vein Competence Centre, Halle, Germany
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Avgerinos ED, Pikoulis E. Editorial: Contemporary Strategies in the Management of Civilian Vascular Trauma. Front Surg 2018; 5:43. [PMID: 29942804 PMCID: PMC6004396 DOI: 10.3389/fsurg.2018.00043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 05/04/2018] [Indexed: 11/23/2022] Open
Affiliation(s)
- Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Emmanouil Pikoulis
- 1st Department of Surgery, University of Athens School of Medicine, National and Kapodistrian University of Athens Medical School, Athens, Greece
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25
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Pikoulis E, Salem KM, Avgerinos ED, Pikouli A, Angelou A, Pikoulis A, Georgopoulos S, Karavokyros I. Damage Control for Vascular Trauma from the Prehospital to the Operating Room Setting. Front Surg 2017; 4:73. [PMID: 29312951 PMCID: PMC5742177 DOI: 10.3389/fsurg.2017.00073] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 11/20/2017] [Indexed: 01/12/2023] Open
Abstract
Early management of vascular injury, starting at the field, is imperative for survival no less than any operative maneuver. Contemporary prehospital management of vascular trauma, including appropriate fluid and volume infusion, tourniquets, and hemostatic agents, has reversed the historically known limb hemorrhage as a leading cause of death. In this context, damage control (DC) surgery has evolved to DC resuscitation (DCR) as an overarching concept that draws together preoperative and operative interventions aiming at rapidly reducing bleeding from vascular disruption, optimizing oxygenation, and clinical outcomes. This review addresses contemporary DCR techniques from the prehospital to the surgical setting, focusing on civilian vascular injuries.
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Affiliation(s)
- Emmanouil Pikoulis
- 1st Department of Surgery, Laiko Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Karim M Salem
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Anastasia Pikouli
- 1st Department of Surgery, Laiko Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Anastasios Angelou
- 1st Department of Surgery, Laiko Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Antreas Pikoulis
- 1st Department of Surgery, Laiko Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Sotirios Georgopoulos
- 1st Department of Surgery, Laiko Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Ioannis Karavokyros
- 1st Department of Surgery, Laiko Hospital, School of Medicine, University of Athens, Athens, Greece
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26
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Abou Ali AN, Salem KM, Alarcon LH, Bauza G, Pikoulis E, Chaer RA, Avgerinos ED. Vascular Shunts in Civilian Trauma. Front Surg 2017; 4:39. [PMID: 28775985 PMCID: PMC5517780 DOI: 10.3389/fsurg.2017.00039] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 07/05/2017] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Adham N Abou Ali
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Karim M Salem
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Louis H Alarcon
- Division of Trauma and General Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Graciela Bauza
- Division of Trauma and General Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Emmanuel Pikoulis
- Uniformed Services University of Health Sciences, Bethesda, MD, United States
| | - Rabih A Chaer
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
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27
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Fernández-Alonso L, Fernández-Alonso S, Aguilar EM. Iliac Artery Reconstruction With the Superficial Femoral Vein After Major Oncologic Resection. Vasc Endovascular Surg 2017; 51:350-351. [PMID: 28474976 DOI: 10.1177/1538574417704559] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The large size of some retroperitoneal tumors and the complex anatomy of the retroperitoneal structures often require en bloc resection of contiguous organs and, sometimes, resection of critical vascular structures. Vascular reconstructive techniques allow reconstruction of major vascular structures, and autologous vein grafting is the preferred option. Although great saphenous vein can be used in select cases, other options must be explored in cases of caliber mismatch between saphenous vein and native vessel. In addition, the use of synthetic grafts should be avoided in potentially infected vascular beds. The use of the superficial femoral vein in such settings is well documented especially in relation to treatment of infected aortic grafts and has the added advantage of appropriate size match for reconstruction of the major abdominal and pelvic vascular structures. Here, we present a case of a 56-year-old woman with a local recurrence of urothelial cancer in the pelvis after radical cystectomy and radiotherapy. Computed tomography (CT) angiography showed the right iliac artery directly involved by the tumor, and vessel resection was necessary to achieve oncologic surgical margins. The tumor was excised en bloc, and vascular reconstruction using the reversed contralateral superficial femoral vein in an end-to-end fashion was performed. The postoperative course was uneventful. Patient was maintained on low-molecular-weight heparin for 1 month and then on low-dose (100 mg acetylsalicylic acid) antiplatelet therapy and compression stockings. Six months later, the patient is asymptomatic, without leg swelling, and the CT scan shows patency of the vascular repair and no tumor recurrence.
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28
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Gopinathan NR, Santhanam SS, Saibaba B, Dhillon MS. Epidemiology of lower limb musculoskeletal trauma with associated vascular injuries in a tertiary care institute in India. Indian J Orthop 2017; 51:199-204. [PMID: 28400667 PMCID: PMC5361472 DOI: 10.4103/0019-5413.201702] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Vascular trauma associated with bony injuries is an orthopaedic emergency. Lack of timely intervention can lead to loss of limb or even life. Inspite of the rising incidence of high speed road traffic accidents in India, there is paucity of literature regarding the demographic pattern, clinical morbidity, management strategies and outcome of arterial injuries associated with lower limb trauma. The aim of this study is to describe the epidemiology and outcome of lower extremity musculoskeletal trauma with associated vascular injuries in a tertiary care institute in India. MATERIALS AND METHODS All individuals who presented to our tertiary care trauma center from July 2013 to December 2014 with lower extremity vascular injury associated with lower limb fractures were identified from a retrospective trauma database for this descriptive study. For the 17 months, there were 82 lower extremity vascular trauma cases admitted in our trauma center, of which 50 cases were included in the study. 32 patients with crush injuries, traumatic amputations, and those with head injury and blunt trauma to chest or abdomen were excluded from the study. RESULTS Out of the 50 cases of lower extremity vascular injury with associated lower limb fractures, 19 limbs were salvaged, 28 amputated, and three patients expired. Young males in the age group of 20-39 years were frequently injured. Motor vehicle accident (MVA) (82%) was found to be the most common cause followed by pedestrian injury. Popliteal artery (62%) was the most common vessel injured, followed by femoral artery (28%). The salvageability percentage was much higher (64%) in the femoral artery injury group when compared to popliteal artery injury group (25%). There were 32 open fractures, with amputation rates (60%) being higher and all three cases of death falling in this group. In addition, the limb salvageability percentage was 43.2% when the patient presented within 12 h of injury and this decreased to a mere 16.7% when the patient had presented more than 24 h after injury. CONCLUSION MVAs are the leading cause of vascular injuries in India. Road safety measures and prevention programs are the need of the hour to prevent these kinds of injuries in the future.
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Affiliation(s)
- Nirmal Raj Gopinathan
- Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Siva Swaminathan Santhanam
- Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India,Address for correspondence: Dr. Siva Swaminathan Santhanam, Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012, India. E-mail:
| | - Balaji Saibaba
- Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Mandeep Singh Dhillon
- Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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29
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Reva VA, Morrison JJ, Denisov AV, Seleznev AB, Zhabin AV, Bozhedomova ER, Samokhvalov IM. Development of an ovine model of occlusive arterial injury for the evaluation of endovascular interventions. Vascular 2015; 24:501-9. [PMID: 26546598 DOI: 10.1177/1708538115615779] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Endovascular intervention for occlusive arterial trauma is becoming more common in clinical practice. The aim of this study is to present an ovine model of extremity arterial injury for use in future endovascular translational research. Animals under general anesthesia had their left superficial femoral artery exposed, which was bluntly injured over a 2-cm section using a hemostat and injection of air. Occlusion was confirmed on angiography and the flow characteristics measured by ultrasonography. Of five animals enrolled, four occluding lesions were created successfully. Post injury, there was a significant reduction in the median (interquartile range) systolic velocity (cm/sec) on the left (injury) compared to the right (control) side (3.5 (0-16.5) vs. 29 (23.8-43.3); p < 0.001). The ovine superficial femoral artery can be used to consistently produce an occlusive lesion that is suitable for use in the future evaluation of endovascular trauma interventions.
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Affiliation(s)
- Viktor A Reva
- Department of War Surgery, Kirov Military Medical Academy, Saint-Petersburg, Russia
| | - Jonathan J Morrison
- Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, UK and The Academic Department of Military Surgery & Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - Alexey V Denisov
- Department of War Surgery, Kirov Military Medical Academy, Saint-Petersburg, Russia
| | - Alexey B Seleznev
- Department of War Surgery, Kirov Military Medical Academy, Saint-Petersburg, Russia
| | - Anatoly V Zhabin
- Department of War Surgery, Kirov Military Medical Academy, Saint-Petersburg, Russia
| | - Elvira R Bozhedomova
- Department of War Surgery, Kirov Military Medical Academy, Saint-Petersburg, Russia
| | - Igor M Samokhvalov
- Department of War Surgery, Kirov Military Medical Academy, Saint-Petersburg, Russia
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30
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Ikeda A, Kudo Y, Maeda M, Tochiki A, Ichimura H, Uesugi M, Jikuya T. Open Surgical Bypass for Superficial Femoral Artery Occlusion Caused by Blunt Trauma. Ann Vasc Dis 2015; 8:258-61. [PMID: 26421079 DOI: 10.3400/avd.cr.15-00030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2015] [Accepted: 06/30/2015] [Indexed: 11/13/2022] Open
Abstract
Blunt vascular trauma of the lower extremities brings about a high amputation rate, because other organ injuries disturb revascularization. We experienced a case of a superficial femoral artery occlusion caused by blunt trauma. The patient also had a femoral bone fracture and a large skin defect with deep muscular injuries of the thigh. We performed a femoropopliteal (FP) bypass using a saphenous vein which was routed through the contaminated wound. Postoperative vacuum-assisted closure therapy was used to prevent graft infection. Surgical bypasses using saphenous veins are approved treatments for arterial occlusions from blunt trauma if the grafts go through contaminated wounds.
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Affiliation(s)
- Akihiko Ikeda
- Department of Cardiovascular Surgery, Tsukuba Medical Center Hospital, Tsukuba, Ibaraki, Japan
| | - Yohei Kudo
- Department of Cardiovascular Surgery, Tsukuba Medical Center Hospital, Tsukuba, Ibaraki, Japan
| | - Michihiro Maeda
- Department of Emergency Medicine, Tsukuba Medical Center Hospital, Tsukuba, Ibaraki, Japan
| | - Aito Tochiki
- Department of Emergency Medicine, Tsukuba Medical Center Hospital, Tsukuba, Ibaraki, Japan
| | - Haruto Ichimura
- Department of Orthopedic Surgery, Tsukuba Medical Center Hospital, Tsukuba, Ibaraki, Japan
| | - Masafumi Uesugi
- Department of Orthopedic Surgery, Tsukuba Medical Center Hospital, Tsukuba, Ibaraki, Japan
| | - Tomoaki Jikuya
- Department of Cardiovascular Surgery, Tsukuba Medical Center Hospital, Tsukuba, Ibaraki, Japan
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31
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Neagoe RM, Bancu S, Muresan M, Sala D. Major vascular injuries complicating knee arthroscopy. Wideochir Inne Tech Maloinwazyjne 2015; 10:266-74. [PMID: 26240627 DOI: 10.5114/wiitm.2015.52559] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 04/14/2015] [Accepted: 05/24/2015] [Indexed: 12/03/2022] Open
Abstract
Starting with a case report, we made a detailed review of the literature, with the purpose of identifying and analyzing the type of iatrogenic vascular lesion following knee arthroscopy and the method of vascular repair. A PubMed literature search was undertaken to locate all reported cases of major vascular iatrogenic injuries during arthroscopic knee procedures. We identified 39 papers which report a total of 62 cases of major iatrogenic popliteal lesions after knee arthroscopy, between 1985 and 2014. The type of arthroscopic intervention performed, the type of iatrogenic vascular lesion encountered, the time passed until its discovery and treatment, the method of vascular reconstruction, and the postoperative course are presented. Postarthroscopy vascular complications are infrequent but potentially disastrous for the condition of the affected inferior limb. An early diagnosis and reintervention are mandatory for a good postoperative outcome.
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32
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Tsuji Y, Kitano I, Tsuji Y, Sawada K. Traumatic disruption of saphenous vein graft bypassed to the dorsalis pedis artery. Ann Vasc Dis 2014; 7:325-7. [PMID: 25298838 DOI: 10.3400/avd.cr.14-00046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2014] [Accepted: 05/29/2014] [Indexed: 11/13/2022] Open
Abstract
We describe a rare case of traumatic disruption of saphenous vein graft bypassed to the dorsalis pedis artery. The vein graft was disrupted at the level of ankle joint by blunt trauma and symptoms of acute foot ischemia were recognized. The injured vein graft was reconstructed with cephalic vein graft interposition. He has been free from any events of foot ischemia at 10 months follow-up with patent vein graft to the dorsalis pedis artery.
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Affiliation(s)
- Yoshihiko Tsuji
- Department of Surgery, Shinsuma General Hospital, Kobe, Hyogo, Japan
| | - Ikuro Kitano
- Department of Surgery, Shinsuma General Hospital, Kobe, Hyogo, Japan
| | - Yoriko Tsuji
- Department of Plastic Surgery, Shinsuma General Hospital, Kobe, Hyogo, Japan
| | - Katsuhiro Sawada
- Department of Surgery, Shinsuma General Hospital, Kobe, Hyogo, Japan
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Abstract
Introduction Extracorporeal shock wave lithotripsy (ESWL) is a well-known and successful treatment modality. In addition, it can be used in premature infants. ESWL is used to treat kidney and ureter stones in children. However, although it is a preferred noninvasive treatment in that setting, there is debate about its long-term effects on growing kidneys in children. Objectives To investigate the long-term effects of pediatric ESWL on renal function in light of updated literature. Methods PubMed and Medline were searched for studies on ESWL in a pediatric population with keywords including efficacy, child, kidney calculi, ureter calculi, lithotripsy, injury, vascular trauma, and shock waves. The research was limited to the English literature during a period from 1980 to 2014. In total, 3,000 articles were evaluated, but only 151 papers were considered. Only the manuscripts directly related to the reviewed subjects were included in the current study. Results However, the acute effects of ESWL in kidney are well-described. Although there are limited studies on the long-term effects of ESWL in children, there is a widespread opinion that ESWL is not affecting renal functions in the long-term. Conclusion ESWL is a safe, effective, and noninvasive treatment option in children. Although ESWL can cause some acute effects in the kidney, there is no long-term effect on the growing kidneys of children.
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Affiliation(s)
- Yigit Akin
- Department of Urology, Harran University School of Medicine, Sanliurfa, Turkey
| | - Selcuk Yucel
- Department of Urology, Acibadem University School of Medicine, Istanbul, Turkey
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Kao ST, Walker PW, Ferguson HW. Posttraumatic arteriovenous malformation of the face: a case report. J Emerg Med 2014; 46:e5-8. [PMID: 24199729 DOI: 10.1016/j.jemermed.2013.08.062] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 05/20/2013] [Accepted: 08/15/2013] [Indexed: 11/22/2022]
Abstract
BACKGROUND Head and neck arteriovenous malformations (AVMs) are reported to occur in 0.1% of the population. Extracranial AVMs account for only 8.1% of head and neck AVMs. Of these, traumatically acquired AVMs of the face are generally reported as quite rare. When secondary to trauma, the lesion is usually supplied by a single vessel, as compared to the multiple vessels often seen with congenital etiology. OBJECTIVES Understanding of regional anatomy is paramount when assessing and managing facial injuries. As an integral health care provider for the facial trauma patient, it is the responsibility of the emergency physician to recognize this rare pathologic lesion necessary to coordinate surgical management of the traumatic AVM. CASE REPORT We present a case report of a patient who sustained a facial laceration complicated by the development of a vascular malformation. The facial laceration in this case report highlights the complexity of wound evaluation and management when treating patients in the emergency department. CONCLUSION Traumatic AVMs are quite rare in the head and neck and are mostly seen in the extremities. Although rare, they have been reported after typical facial trauma as well as elective surgical procedures. The management of such lesions may include selective embolization or surgical exploration with ligation. Emergency physicians and facial trauma surgeons are challenged with recognizing and treating these rare but very real vascular lesions. It is our hope that this case report provides an overview of posttraumatic AVMs in the head and neck.
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Dregelid EB, Pedersen G. Treatment of major vein injury with the hemostatic fleece TachoSil by interposing a peritoneal patch to avoid vein thrombosis: A feasibility study in pigs. J Emerg Trauma Shock 2011; 4:77-81. [PMID: 21633573 PMCID: PMC3097586 DOI: 10.4103/0974-2700.76822] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2010] [Accepted: 09/07/2010] [Indexed: 11/13/2022] Open
Abstract
Background: Vein lacerations in awkward locations are difficult to repair and carry high mortality. The hemostatic fleece, TachoSil, is effective in preventing intraoperative bleeding in different settings, but has not been recommended for use in large vein injury. TachoSil with a peritoneal patch interposed to avoid vein thrombosis has been reported as a method to obtain hemostasis in vein laceration, but further studies of this method are needed. Materials and Methods: A 1.5 × 1 cm defect was created in the vena cava in five pigs. A 26 × 32 mm peritoneal patch was applied on the coagulant side of a 48 × 48 mm TachoSil sheet, and used to cover the defect. Light compression with a wet sponge was applied for 3 min. No vascular suturing was performed. Results: Successful hemostasis was obtained in four out of the five pigs although the minimum TachoSil gluing zone surrounding the peritoneal patch was only 0–2 mm. The fifth pig died of hemorrhage 30 min after surgery due to a 4-mm stretch with no TachoSil gluing zone outside the peritoneal patch. At six days postoperatively the peritoneal patch was well integrated into the vein wall. After 28 days, the peritoneal patch was almost indiscernible from surrounding vein endothelium. Conclusions: Vein wall defects can be repaired using TachoSil with a peritoneal patch interposed to prevent contact between the thrombogenic TachoSil sheet and the vein lumen. An adequate TachoSil gluing zone all around the patch is essential.
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Affiliation(s)
- Einar B Dregelid
- Department of Vascular Surgery, Haukeland University Hospital, Norway
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36
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Mohammadzade MA, Mohammadzade M, Herfatkar MR. A comparison of interposition and femoropopliteal bypass grafts in the management of popliteal artery trauma. Iran J Med Sci 2011; 36:32-5. [PMID: 23365475 PMCID: PMC3559114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Revised: 11/02/2010] [Accepted: 11/14/2010] [Indexed: 11/11/2022]
Abstract
BACKGROUND Peripheral vascular injury associated with lower limb trauma is a well-known emergency. The experience for the management of popliteal artery trauma have mainly come from managing the traumas of military personnels during Iran-Iraq war. The present study compared the effects of two currently-used surgical techniques in the management of popliteal trauma, namley femoropopliteal bypass graft and interposition vein graft on limb salvage. METHODS A retrospective review of 40 patients with popliteal artery trauma admitted to the trauma unit of a university teaching hospital during 2003 to 2008. The patients had undergone femoropopliteal bypass graft (n=26) or interposition vein graft (n=14) for the management of popliteal trauma. RESULTS The amputation rate among patients managed by femoropopliteal bypass or interposition vein graft was 35.7% and 61.5%, respectively. Knee stability among patients managed by interposition graft group was 57.7% and in those managed by femoropopliteal bypass graft was 85.7%. CONCLUSION The rates of knee stability achieved by the employed techniques indicate that femoropopliteal bypass vein graft is superior, and therefore, preferable to the interposition vein graft in the management of popliteal artery trauma.
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Affiliation(s)
| | - Maryam Mohammadzade
- Depatrment of General and Vascular Surgery, Guilan University of Medical Sciences,Rasht, Iran
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Belczak S, Silva ESD, Aun R, Sincos IR, Belon AR, Casella IB, Gornati V, Figueiredo LLFPD. Endovascular treatment of peripheral arterial injury with covered stents: an experimental study in pigs. Clinics (Sao Paulo) 2011; 66:1425-30. [PMID: 21915495 PMCID: PMC3161223 DOI: 10.1590/s1807-59322011000800020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Accepted: 04/26/2011] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To evaluate the feasibility of using endovascular repair to treat penetrating arterial injuries with covered stents. Feasibility was examined according to the circumferential extent of the injury. INTRODUCTION Surgical trauma often increases the risk of major morbidity and mortality associated with vascular injury, and endovascular repair has many advantages in such situations. METHODS Twenty white male domestic pigs weighing 28-38 kg with controlled vascular injuries were divided into four equal groups according to the circumferential extent of their vascular lesion (i.e., no lesion, lesion <50%, lesion >50%, and complete lesion). The left common carotid artery was dissected with proximal and distal control, and this procedure was followed by controlled sectioning of the arterial wall. Local manual compression was applied for 10 min and was followed by endovascular repair with the placement of a 5x50 mm VIABHAN TM covered stent using the femoral approach. We also monitored additional variables, such as the duration of the procedures (the mean was 56.3 ± 19.1 min), ultrasound parameters (e.g., maximum arterial diameter, peak systolic and diastolic velocity, and resistance index), arteriography findings, and fluctuations in vital signs (e.g., cardiac output, arterial pressure, and central venous pressure). RESULTS The experimental procedure was found to be feasible and reproducible. Repairs were successful in all animals in the control (no lesion) and <50% lesion groups. Success was also achieved in four out of five pigs in the >50% group and in one pig in the complete lesion group. DISCUSSION The endovascular repair of an arterial injury is possible, but success depends on the circumferential extent of the arterial lesion. The present experimental model, which involved endovascular techniques, highlighted important factors that must be considered in future studies involving similar animals and materials.
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Affiliation(s)
- Sergio Belczak
- Cirurgia Vascula - Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil.
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Abstract
Shock wave lithotripsy (SWL) has proven to be a highly effective treatment for the removal of kidney stones. Shock waves (SWs) can be used to break most stone types, and because lithotripsy is the only noninvasive treatment for urinary stones, SWL is particularly attractive. On the downside SWL can cause vascular trauma to the kidney and surrounding organs. This acute SW damage can be severe, can lead to scarring with a permanent loss of functional renal volume, and has been linked to potentially serious long-term adverse effects. A recent retrospective study linking lithotripsy to the development of diabetes mellitus has further focused attention on the possibility that SWL may lead to life-altering chronic effects. Thus, it appears that what was once considered to be an entirely safe means to eliminate renal stones can elicit potentially severe unintended consequences. The purpose of this review is to put these findings in perspective. The goal is to explain the factors that influence the severity of SWL injury, update current understanding of the long-term consequences of SW damage, describe the physical mechanisms thought to cause SWL injury, and introduce treatment protocols to improve stone breakage and reduce tissue damage.
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Affiliation(s)
- James A McAteer
- Department of Anatomy and Cell Biology, Indiana University School of Medicine, Indianapolis, IN 46202-5120, USA.
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