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Cifuentes S, Ulloa JH, Rasmussen TE. An Implantable Bioprosthetic Venous Valve to Establish Deep Vein Competence for Post-Thrombotic Syndrome. JAMA Surg 2023; 158:316-317. [PMID: 36652222 DOI: 10.1001/jamasurg.2022.6362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
This article discusses the VenoValve bioprosthetic device, which is designed to improve valvular competence in the deep venous system of the lower extremities and treat deep venous insufficiency.
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Cirillo-Penn NC, DeMartino RR, Rasmussen TE, Shuja F, Colglazier JJ, Kalra M, Oderich GS, Mendes BC. Midterm Clinical Outcomes of Retrograde Open Mesenteric Stenting for Mesenteric Ischemia. Ann Vasc Surg 2023; 89:20-27. [PMID: 36404451 DOI: 10.1016/j.avsg.2022.09.062] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 08/03/2022] [Accepted: 09/26/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Retrograde open mesenteric stenting (ROMS) has become a mainstay in treatment of mesenteric ischemia; however, follow-up in contemporary studies is limited. METHODS A single-center retrospective review of patients undergoing ROMS from 2007 to 2020 was conducted. Demographics, presentation, and procedural details were reviewed. End points were morbidity and mortality, technical success, primary patency, reinterventions, and freedom from clinical recurrence. RESULTS ROMS was performed in 34 patients, 19 female (56%). Mean age was 71 ± 10 years. Eighteen patients (53%) presented with acute mesenteric ischemia (AMI), 11 (32%) with acute-on-chronic, and 5 (15%) with chronic mesenteric ischemia. Etiology was chronic atherosclerosis with/without in-situ thrombosis in 28 patients (82%), superior mesenteric artery dissection in 3, and 1 each with embolic, vasculitic, and nonocclusive ischemia. Four patients (12%) had prior mesenteric procedures (3 Celiac/1 superior mesenteric artery stent) and 1 had unsuccessful transbrachial stenting attempt. Technical success, defined as successful stenting through a retrograde approach was attained in 31 patients (91%), with the 3 remaining patients treated with transbrachial stenting in 2 and iliomesenteric bypass in 1. Covered stents were used in 21 patients (64%) with or without stent extension with bare-metal stents. Eight patients (23%) required thromboembolectomy and 9 (26%) underwent patch angioplasty. Thirty-day mortality rate was 35%, all in patients with AMI (10) or acute-on-chronic (2). Eighteen patients (53%) underwent bowel resection, all presenting acutely. Early reinterventions within the first 30 days were required in 5 patients (15%), including 2 redo ROMS with thrombectomy and endarterectomy, 2 percutaneous stent extensions, and 1 aortic septum fenestration with coiling of a jejunal branch pseudoaneurysm. With a median follow-up of 3.7 (interquartile range: 0.8-5.0) years, in patients surviving discharge, 5 required reintervention yielding freedom from reintervention rates of 87% at 1 year and 71% at 3 years. All postdischarge reinterventions were endovascular with no conversion to bypass. The overall 1-year and 3-year primary patency rates were 70% and 61% (primary-assisted patency at 1 and 3 years was 87% and secondary patency at 1 and 3 years was 97%). The freedom from symptom recurrence was 95% at 1 and 3 years. CONCLUSIONS ROMS carries high rates of technical success in patients with mesenteric ischemia, despite a high chronic atherosclerotic burden. Although mid-term patency rates are acceptable, AMI is still associated with high early morbidity and mortality, with high rates of associated bowel resection. ROMS is a valuable tool in the armamentarium of vascular surgeons.
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Sen I, Kanzafarova I, Yonkus J, Mendes BC, Colglazier JJ, Shuja F, DeMartino RR, Kalra M, Rasmussen TE. Clinical presentation, operative management, and long-term outcomes of rupture after previous abdominal aortic aneurysm repair. J Vasc Surg 2023; 77:396-405.e7. [PMID: 36272507 DOI: 10.1016/j.jvs.2022.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 07/30/2022] [Accepted: 08/08/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The aim of the present study was to evaluate the presentation trends, intervention, and survival of patients who had been treated for late abdominal aortic aneurysm rupture (LAR) after open repair (OR) or endovascular aortic aneurysm repair (EVAR). METHODS We reviewed the clinical data from a single-center, retrospective database for patients treated for LAR from 2000 to 2020. The end points were the 30-day mortality, major postoperative complication, and survival. The outcomes between LAR managed with EVAR (group I) vs OR were compared (group II). RESULTS Of 390 patients with infrarenal aortic rupture, 40 (10%) had experienced aortic rupture after prior aortic repair and comprised the LAR cohort (34 men; age 78 ± 8 years). LAR had occurred before EVAR in 30 and before OR in 10 patients. LAR was more common in the second half of the study with 32 patients after 2010. LAR after prior OR was secondary to ruptured para-anastomotic pseudoaneurysms. After initial EVAR, LAR had occurred despite reintervention in 17 patients (42%). The time to LAR was shorter after prior EVAR than after OR (6 ± 4 vs 12 ± 4 years, respectively; P = .003). Treatment for LAR was EVAR for 25 patients (63%; group I) and OR for 15 (37%, group II). LAR after initial OR was managed with endovascular salvage for 8 of 10 patients. Endovascular management was more frequent in the latter half of the study period. In group I, fenestrated repair had been used for seven patients (28%). Salvage for the remaining cases was feasible with EVAR, aortic cuffs, or limb extensions. The incidence of free rupture, time to treatment, 30-day mortality (8% vs 13%; P = .3), complications (32% vs 60%; P = .1), and disposition were similar between the two groups. Those in group I had had less blood loss (660 vs 3000 mL; P < .001) and less need for dialysis (0% vs 33%; P < .001) than those in group II. The median follow-up was 21 months (interquartile range, 6-45 months). The overall 1-, 3-, and 5-year survival was 76%, 52%, and 41%, respectively, and was similar between groups (28 vs 22 months; P = .48). Late mortality was not related to the aorta. CONCLUSIONS LAR after abdominal aortic aneurysm repair has been encountered more frequently in clinical practice, likely driven by the frequency of EVAR. However, most LARs, including those after previous OR, can now be salvaged with endovascular techniques with lower morbidity and mortality.
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Rasmussen TE. Focused Empiricism and the Efficacy of Resuscitative Endovascular Balloon Occlusion of the Aorta. JAMA Surg 2023; 158:150-151. [PMID: 36542387 DOI: 10.1001/jamasurg.2022.6430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Edwards J, Stonko DP, Abdou H, Treffalls RN, Walker P, Rasmussen TE, Propper BW, Morrison JJ. Lower Extremity Extracorporeal Distal Revascularization in a Swine Model of Prolonged Extremity Ischemia. Ann Vasc Surg 2023; 89:293-301. [PMID: 36441096 DOI: 10.1016/j.avsg.2022.09.060] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 09/25/2022] [Accepted: 09/27/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Acute arterial occlusion of the lower extremity is a time-dependent emergency that requires prompt revascularization. Lower extremity extracorporeal distal revascularization (LEEDR) is a technique that can be initiated bedside when definitive therapy is delayed. The aim of this study is to evaluate this technique in a swine model of prolonged extremity ischemia. METHODS Anesthetized swine underwent right femoral and left posterior tibial artery cannulation, left iliac venous flow monitoring (mL/min), and continuous left anterior compartment pressure (CP) monitoring (mm Hg). The iliac artery was clamped for 6 hr. LEEDR animals underwent 5 hr of extracorporeal femoral-to-tibial blood flow at 150 mL/min; controls had no intervention. At 6 hr, LEEDR was discontinued, iliac flow restored, and anterior CP monitored for 3 hr. RESULTS Baseline characteristics were similar across both the groups. Iliac clamping saw an expected fall in iliac venous flow (258 ± 30 to 82 ± 19; P < 0.001). LEEDR resulted in a rise in iliac venous flow (82 ± 20 to 181 ± 16; P < 0.001); control arm flow remained reduced (71 ± 8; P < 0.001). Once inflow was restored, venous flow returned to baseline. Revascularization provoked a higher peak CP in the control arm versus in the LEEDR group (25 ± 5 vs. 6 ± 1; P = 0.02). CONCLUSIONS An extracorporeal circuit can temporarily revascularize an extremity in a swine model of prolonged ischemia, mitigating reperfusion injury and maintaining normal CPs. This concept should undergo further evaluation as a bedside tool to mitigate extremity ischemia prior to definitive revascularization.
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Anderson PB, Sen I, Rasmussen TE. Hybrid management of critical limb ischemia with a novel bioengineered vascular conduit. J Vasc Surg Cases Innov Tech 2022; 9:101079. [PMID: 36747608 PMCID: PMC9898777 DOI: 10.1016/j.jvscit.2022.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 11/17/2022] [Indexed: 12/23/2022] Open
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Polcz JE, Ronaldi AE, Madurska M, Bedocs P, Leung LY, Burmeister DM, White PW, Rasmussen TE, White JM. Next-Generation REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) Device Precisely Achieves Targeted Regional Optimization in a Porcine Model of Hemorrhagic Shock. J Surg Res 2022; 280:1-9. [PMID: 35939866 DOI: 10.1016/j.jss.2022.06.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 05/13/2022] [Accepted: 06/04/2022] [Indexed: 10/16/2022]
Abstract
INTRODUCTION Limitations such as time-dependent distal ischemia have slowed the adoption of resuscitative endovascular balloon occlusion of the aorta (REBOA) for noncompressible hemorrhage. Next-generation REBOA technologies may allow for controlled partial flow, known as targeted regional optimization, to reduce distal ischemia. We aimed to characterize the efficacy of one such catheter in a porcine model of lethal hemorrhagic shock. METHODS Noncompressible hemorrhage from an iliac injury was induced in anesthetized swine (Sus scrofa) (70-90 kg), targeting 30% total blood volume. Animals were then randomized to partial aortic occlusion (PO) with targeted distal mean arterial pressure (MAP) of 35-40 mm of mercury (mm Hg) and complete aortic occlusion (CO) (n = 8 per group) for 90 min. All groups were then resuscitated during a two-h critical care (CC) phase, with flow rate and MAP recorded continuously at the distal infrarenal aorta and proximal carotid artery, and analyzed with two-way repeated measures analysis of variance with S-N-K post-hoc test. RESULTS During aortic occlusion, MAP distal to the balloon was consistently maintained at 35.8 ± 0.3 mm Hg in the PO group compared to 27.1 ± 0.3 mm Hg in the CO group (P < 0.05), which also corresponded to higher flow rates (202.9 ± 4.8 mL/min PO versus 25.9 ± 0.8 mL/min CO; P < 0.05). MAP proximal to the balloon was significantly higher with CO versus PO (109.2 ± 2.3 mm Hg versus 85.2 ± 2.3 mm Hg; P < 0.05). During the CC phase, distal aortic flow and MAP were not significantly different between groups. However, creatinine returned to baseline levels by the end of the study in the PO group, but not the CO group. One animal died in the CO group, whereas none died in the PO group. CONCLUSIONS This is the first examination of the next-generation pREBOA-PRO in a porcine model of lethal hemorrhagic shock. We show technical feasibility of this technique to precisely achieve targeted regional optimization without device failure or complication. The ability to titrate balloon inflation and thus distal flow/pressure may extend the therapeutic window of REBOA by mitigating distal ischemia.
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Perkins ZB, Kersey AJ, White JM, Lauria AL, Propper BW, Tai NRM, Rasmussen TE. Impact of Ischemia Duration on Lower Limb Salvage in Combat Casualties. Ann Surg 2022; 276:532-538. [PMID: 35972512 DOI: 10.1097/sla.0000000000005560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The 6-hour threshold to revascularization of an ischemic limb is ubiquitous in the trauma literature, however, contemporary evidence suggests that this threshold should be less. This study aims to characterize the relationship between the duration of limb ischemia and successful limb salvage following lower extremity arterial trauma. METHODS This is a cohort study of the United States and UK military service members injured while serving in Iraq or Afghanistan between 2003 and 2013. Consecutive patients who sustained iliac, femoral, or popliteal artery injuries, and underwent surgery to attempt revascularization, were included. The association between limb outcome and the duration of limb ischemia was assessed using the Kaplan-Meier method. RESULTS One hundred twenty-two patients (129 limbs) who sustained iliac (2.3%), femoral (56.6%), and popliteal (41.1%) arterial injuries were included. Overall, 87 limbs (67.4%) were successfully salvaged. The probability of limb salvage was 86.0% when ischemia was ≤1 hour; 68.3% when between 1 and 3 hours; 56.3% when between 3 and 6 hours; and 6.7% when >6 hours ( P <0.0001). Shock more than doubled the risk of failed limb salvage [hazard ratio=2.42 (95% confidence interval: 1.27-4.62)]. CONCLUSIONS Limb salvage is critically dependent on the duration of ischemia with a 10% reduction in the probability of successful limb salvage for every hour delay to revascularization. The presence of shock significantly worsens this relationship. Military trauma systems should prioritize rapid hemorrhage control and early limb revascularization within 1 hour of injury.
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Anderson PB, Sen I, Welker CC, Rasmussen TE, Ramakrishna H. Critical Limb Ischemia: Update for the Cardiovascular Anesthesiologist. J Cardiothorac Vasc Anesth 2022; 36:3939-3944. [DOI: 10.1053/j.jvca.2022.06.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 06/24/2022] [Indexed: 11/11/2022]
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Lauria AL, Sen I, Rasmussen TE. The Human Acellular Vessel for Vascular Reconstruction or Bypass: A Novel Biologic Conduit for Vascular Bypass and Repair. JAMA Surg 2022; 157:731-732. [PMID: 35731527 DOI: 10.1001/jamasurg.2022.1214] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Madurska MJ, Abdou H, Elansary NN, Edwards J, Patel N, Stonko DP, Richmond MJ, Scalea TM, Rasmussen TE, Morrison JJ. Whole Blood Selective Aortic Arch Perfusion for Exsanguination Cardiac Arrest: Assessing Myocardial Tolerance to the Duration of Cardiac Arrest. Shock 2022; 57:243-250. [PMID: 35759304 DOI: 10.1097/shk.0000000000001946] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Selective aortic arch perfusion (SAAP) is an endovascular technique that consists of aortic occlusion with perfusion of the coronary and cerebral circulation. It been shown to facilitate return of spontaneous circulation (ROSC) after exanguination cardiac arrest (ECA), but it is not known how long arrest may last before the myocardium can no longer be durably recovered. The aim of this study is to assess the myocardial tolerance to exsanguination cardiac arrest before successful ROSC with SAAP. METHODS Male adult swine (n = 24) were anesthetized, instrumented, and hemorrhaged to arrest. Animals were randomized into three groups: 5, 10, and 15 min of cardiac arrest before resuscitation with SAAP. Following ROSC, animals were observed for 60 min in a critical care environment. Primary outcomes were ROSC, and survival at 1-h post-ROSC. RESULTS Shorter cardiac arrest time was associated with higher ROSC rate and better 1-h survival. ROSC was obtained for 100% (8/8) of the 5-min ECA group, 75% (6/8) of the 10-min group, 43% (3/7) of the 15-min group (P = 0.04). One-hour post-ROSC survival was 75%, 50%, and 14% in 5-, 10-, and 15-min groups, respectively (P = 0.02). One-hour survivors in the 5-min group required less norepinephrine (1.31 mg ± 0.83 mg) compared with 10-SAAP (0.76 mg ± 0.24 mg), P = 0.008. CONCLUSION Whole blood SAAP can accomplish ROSC at high rates even after 10 min of unsupported cardiac arrest secondary to hemorrhage, with some viability beyond to 15 min. This is promising as a tool for ECA, but requires additional optimization and clinical trials.Animal Use Protocol, IACUC: 0919015.
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Edwards J, Abdou H, Patel N, Madurska MJ, Poe K, Bonin JE, Richmond MJ, Rasmussen TE, Morrison JJ. The functional vascular anatomy of the swine for research. Vascular 2022; 30:392-402. [PMID: 33813971 DOI: 10.1177/1708538121996500] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Swine (Sus Scrofa) are utilized broadly in research settings, given similarities to human vessel size and function; however, there are some important differences for clinicians to understand in order to interpret and perform translational research. This review article uses angiograms acquired in the course of a translational research program to present a description of the functional anatomy of the swine. METHODS Digital subtraction angiography and computed tomography angiography were obtained throughout the course of multiple studies utilizing power injection with iodinated contrast. Subtracted two-dimensional images and three-dimensional multiplanar reformations were utilized post image acquisition to create maximal intensity projections and three-dimensional renderings of using open-source software (OsiriX). These imaging data are presented along with vessel measurements for reference. RESULTS An atlas highlighting swine vascular anatomy, with an emphasis on inter-species differences that may influence how studies are conducted and interpreted, was compiled. CONCLUSIONS Swine are utilized in broad-reaching fields for preclinical research. While many similarities between human and swine vasculature exist, there are important differences to consider when conducting and interpreting research. This review article highlights these differences and presents accompanying images to inform clinicians gaining experience in swine research.
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Moore LJ, Rasmussen TE. A contemporary assessment of resuscitative endovascular balloon occlusion of the aorta. J Trauma Acute Care Surg 2022; 92:762-764. [PMID: 35121706 DOI: 10.1097/ta.0000000000003556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Lauria AL, Kersey AJ, Propper BW, White PW, Clouse WD, Calderon DR, Rasmussen TE, White JM. Real World Experience with the Human Acellular Vessel: A Bioengineered Implant for Arterial Repair that Expands Limb Salvage Options. Ann Vasc Surg 2022. [DOI: 10.1016/j.avsg.2021.12.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Cirillo-Penn NC, DeMartino RR, Rasmussen TE, Shuja F, Colglazier JJ, Kalra M, Oderich GS, Mendes BC. Midterm Clinical Outcomes Of Retrograde Open Mesenteric Stenting For Mesenteric Ischemia. Ann Vasc Surg 2022. [DOI: 10.1016/j.avsg.2021.12.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Edwards J, Abdou H, Patel N, Lang E, Richmond MJ, Rasmussen TE, Scalea TM, Morrison JJ. Open chest selective aortic arch perfusion vs open cardiac massage as a means of perfusion during in exsanguination cardiac arrest: a comparison of coronary hemodynamics in swine. Eur J Trauma Emerg Surg 2022; 48:2089-2096. [PMID: 34984495 DOI: 10.1007/s00068-021-01810-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 10/25/2021] [Indexed: 11/29/2022]
Abstract
AIM To describe and compare the aortic-right atrial pressure (AoP-RAP) gradients and mean coronary perfusion pressures (CPPs) generated during open chest selective aortic arch perfusion (OCSAAP) with those generated during open cardiac massage (OCM) in hypovolemic swine. METHODS Ten male Hanford swine utilized in a prior poly-trauma study were included in the study. Animals were rendered hypovolemic via a 30% volume bleed. Upon confirmation of death, animals underwent immediate clamshell thoracotomy and aortic cross-clamping followed by 5 min of OCM. A catheter suitable for OCSAAP was then inserted into the aorta and animals underwent 1 min of OCSAAP at a rate of 10 mL/kg/min. Aortic and right atrial pressures were recorded continuously using solid-state blood pressure catheters. Representative 10-s intervals from each resuscitation method were extracted. Hemodynamic parameters including AoP-RAP gradients and CPPs were calculated and compared. RESULTS At baseline, time from death to intervention was significantly shorter for OCM. However, mean CPPs and AoP-RAP gradients were significantly higher in animals undergoing OCSAAP. 98% of OCSAAP segments had a mean CPP > 15, compared to 35% of OCM intervals. While OCM had a significant negative correlation between time to intervention and maximum CPP, this correlation was not significant for OCSAAP. CONCLUSION OCSAAP generates favorable and potentially time-resistant pressure gradients when compared to those generated by OCM. Further investigation of the technique of OCSAAP is warranted, as it may have potential utility as a therapy during resuscitative thoracotomy (RT).
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Qasim Z, Butler FK, Holcomb JB, Kotora JG, Eastridge BJ, Brohi K, Scalea TM, Schwab CW, Drew B, Gurney J, Jansen JO, Kaplan LJ, Martin MJ, Rasmussen TE, Shackelford SA, Bank EA, Braude D, Brenner M, Guyette FX, Joseph B, Hinckley WR, Sperry JL, Duchesne J. Selective Prehospital Advanced Resuscitative Care - Developing a Strategy to Prevent Prehospital Deaths From Noncompressible Torso Hemorrhage. Shock 2022; 57:7-14. [PMID: 34033617 DOI: 10.1097/shk.0000000000001816] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Hemorrhage, and particularly noncompressible torso hemorrhage remains a leading cause of potentially preventable prehospital death from trauma in the United States and globally. A subset of severely injured patients either die in the field or develop irreversible hemorrhagic shock before they can receive hospital definitive care, resulting in poor outcomes. The focus of this opinion paper is to delineate (a) the need for existing trauma systems to adapt so that potentially life-saving advanced resuscitation and truncal hemorrhage control interventions can be delivered closer to the point-of-injury in select patients, and (b) a possible mechanism through which some trauma systems can train and incorporate select prehospital advanced resuscitative care teams to deliver those interventions.
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Owattanapanich N, Biswas S, Benjamin ER, Rasmussen TE, Shackelford S, Demetriades D. Injury Patterns and Outcomes in Civilian and Military Abdominal Gunshot Wounds. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Lauria AL, White JM, Kersey AJ, White PW, Rasmussen TE. Bioengineered Acellular Vessel Implantation in a Patient with Chronic Limb-Threatening Ischemia: A Case Report and Discussion of Implications for Trauma. JOURNAL OF ENDOVASCULAR RESUSCITATION AND TRAUMA MANAGEMENT 2021. [DOI: 10.26676/jevtm.v5i2.197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The ideal conduit for vascular reconstruction is one that can be obtained “off the shelf” and demonstrates long-term patency, tissue incorporation and resistance to infection. Currently available conduits, such as autologous vein and synthetic grafts, are limited in one or more of these areas. The Human Acellular Vessel (HAV), a bioengineered, acellular blood vessel, can be obtained “off the shelf” and has shown promise in each of these properties. We describe a case in which the HAV was utilized for open bypass reconstruction in a patient with chronic limb-threatening ischemia who lacked alternative reconstructive options. The case is followed by a discussion of potential broader applications of this novel implant, specifically in the management of vascular trauma.
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Ronaldi AE, Madurska MJ, Bozzay JD, Polcz JE, Baer DG, Burmeister DM, White PW, Rasmussen TE, White JM. Targeted Regional Optimization: Increasing the Therapeutic Window for Endovascular Aortic Occlusion In Traumatic Hemorrhage. Shock 2021; 56:493-506. [PMID: 34014887 DOI: 10.1097/shk.0000000000001814] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
ABSTRACT Resuscitative endovascular balloon occlusion of the aorta (REBOA) allows for effective temporization of exsanguination from non-compressible hemorrhage (NCTH) below the diaphragm. However, the therapeutic window for aortic occlusion is time-limited given the ischemia-reperfusion injury generated. Significant effort has been put into translational research to develop new strategies to alleviate the ischemia-reperfusion injury and extend the application of endoaortic occlusion. Targeted regional optimization (TRO) is a partial REBOA strategy to augment proximal aortic and cerebral blood flow while targeting minimal threshold of distal perfusion beyond the zone of partial aortic occlusion. The objective of TRO is to reduce the degree of ischemia caused by complete aortic occlusion while providing control of distal hemorrhage. This review provides a synopsis of the concept of TRO, pre-clinical, translational experiences with TRO and early clinical outcomes. Early results from TRO strategies are promising; however, further studies are needed prior to large-scale implementation into clinical practice.
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Khalifeh A, Bower TC, Kalra M, Rasmussen TE, Mendes BC, Colglazier J, De Martino RR, Shuja F. Open Surgical Revascularization for Aortoiliac Occlusive Disease Across Surgical Eras and Surgeon Experience. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.07.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Engberg M, Hörer T, Rasmussen TE, Taudorf M, Nayahangan LJ, Rasmussen NK, Russell L, Konge L, Lönn L. Developing a tool to assess competence in resuscitative endovascular balloon occlusion of the aorta: An international Delphi consensus study. J Trauma Acute Care Surg 2021; 91:310-317. [PMID: 34259442 DOI: 10.1097/ta.0000000000003191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an emergency procedure that is potentially lifesaving in major noncompressible torso hemorrhage. It may also improve outcome in nontraumatic cardiac arrest. However, the procedure can be technically challenging and requires the immediate presence of a qualified operator. Thus, evidence-based training and assessment of operator skills are essential for successful implementation and patient safety. A prerequisite for this is a valid and reliable assessment tool specific for the procedure. The aim of this study was to develop a tool for assessing procedural competence in REBOA based on best-available knowledge from international experts in the field. METHODS We invited international REBOA experts from multiple specialties to participate in an anonymous three-round iterative Delphi study to reach consensus on the design and content of an assessment tool. In round 1, participants suggested items to be included. In rounds 2 and 3, the relevance of each suggested item was evaluated by all participants to reach consensus. Interround data processing was done systematically by a steering group. RESULTS Forty panelists representing both clinical and educational expertise in REBOA from 16 countries (in Europe, Asia, and North and South America) and seven different specialties participated in the study. After 3 Delphi rounds and 532 initial item suggestions, the panelists reached consensus on a 10-item assessment tool with behaviorally anchored rating scales. It includes assessment of teamwork, procedure time, selection and preparation of equipment, puncture technique, guidewire handling, sheath handling, placement of REBOA catheter, occlusion, and evaluation. CONCLUSION We present the REBOA-RATE assessment tool developed systematically by international experts in the field to optimize content validity. Following further studies of its validity and reliability, this tool represents an important next step in evidence-based training programs in REBOA, for example, using mastery learning. LEVEL OF EVIDENCE Therapeutic, level V.
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Ronaldi AE, Polcz JE, Robertson HT, Walker PF, Bozzay JD, Dubose JJ, White PW, Rasmussen TE, White JM. A multi-registry analysis of military and civilian penetrating cervical carotid artery injury. J Trauma Acute Care Surg 2021; 91:S226-S232. [PMID: 34039922 DOI: 10.1097/ta.0000000000003296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Penetrating cervical carotid artery injury is an uncommon but high-stake scenario associated with stroke and death. The objective of this study was to characterize and compare penetrating carotid injury in the military and civilian setting, as well as provide considerations for management. METHODS Cohorts with penetrating cervical carotid artery injury from the Department of Defense Trauma Registry (2002-2015) and the American Association for the Surgery of Trauma Prospective Observation Vascular Injury Treatment Registry (2012-2018) were analyzed. A least absolute shrinkage and selection operator multivariate analysis using random forest-based imputation was performed to identify risk factors affecting stroke and mortality. RESULTS There were a total of 157 patients included in the study, of which 56 (35.7%) were military and 101 (64.3%) were civilian. The military cohort was more likely to have been managed with open surgery (87.5% vs. 44.6%, p < 0.001) and to have had any procedure to restore or maintain flow to the brain (71.4% vs. 35.6%, p < 0.001), while the civilian cohort was more likely to undergo nonoperative management (45.5% vs. 12.5%, p < 0.001). Stroke rate was higher within the military cohort (41.1% vs. 13.9%, p < 0.001); however, mortality did not differ between the groups (12.5% vs. 17.8%, p = 0.52). On multivariate analysis, predictors for stroke were presence of a battle injury (log odds, 2.1; p < 0.001) and internal or common carotid artery ligation (log odds 1.5, p = 0.009). For mortality outcome, protective factors included a high Glasgow Coma Scale on admission (log odds, -0.21 per point; p < 0.001). Increased admission Injury Severity Score was a predictor of mortality (log odds, 0.05 per point; p = 0.005). CONCLUSION The stroke rate was higher in the military cohort, possibly reflecting complexity of injury; however, there was no difference in mortality between military and civilian patients. For significant injuries, concerted efforts should be made at carotid reconstruction to reduce the occurrence of stroke. LEVEL OF EVIDENCE Retrospective cohort analysis, level III.
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Madurska MJ, Elansary NN, Pate N, Edwards J, Richmond MJ, Scalea TM, Rasmussen TE, Morrison JJ. O10 Myocardial tolerance to exsanguination and retrieval using whole blood-selective aortic arch perfusion. Br J Surg 2021. [DOI: 10.1093/bjs/znab282.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Abstract
Introduction
Exsanguination cardiac arrest is the leading preventable cause of death in trauma. Treatment modalities are limited, and prognosis remains dismal. Selective aortic arch perfusion (SAAP) is an emerging endovascular resuscitation technique consisting of aortic occlusion and perfusion of coronary and cerebral circulation with oxygenated resuscitation fluid. Translational research has demonstrated promising outcomes; however, little is known about the duration of cardiac arrest beyond which the myocardium cannot be resuscitated. The aims of this study are to assess the myocardial tolerance to exsanguination cardiac arrest before successful return of spontaneous circulation (ROSC) following resuscitation with SAAP, and 1-hour survival.
Method
23 male adult swine were anaesthetised and instrumented. Controlled hemorrhage was performed until cardiac arrest defined by MAP <20 mmHg. Animals were randomized into 3 groups: 5, 10 and 15 minutes of cardiac arrest before resuscitation with SAAP. Following ROSC animals were observed for 60 minutes.
Result
Baseline characteristics were similar between groups (P > 0.05). ROSC was 100% (8/8) in the 5 min group, 75% (6/8) and 43% (3/7) in 10- and 15-min groups respectively (P = 0.042). 60 min survival was 75%, 50% and 14% in 5-, 10- and 15-min groups respectively (P = 0.015). 1-hour survivors in the 5 min group required less noradrenaline 23.6 (±7.4) compared to other animals 40.9 (±25.8), (P = 0.008).
Conclusion
Selective aortic arch perfusion is an effective resuscitative tool in eliciting ROSC in a swine model of exsanguination cardiac arrest lasting >5 min. Sustainable resuscitability using SAAP declines after 10 min of exsanguination cardiac arrest.
Take-home Message
SAAP is an emerging resuscitation technique with promising outcomes in exsanguination cardiac arrest and may be a segway to Extracorporeal life support. The time limit for resuscitability of the myocardium lies somewhere between 10 and 15 min after the start of exsanguination cardiac arrest.
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Russo RM, Davidson AJ, Alam HB, DuBose JJ, Galante JM, Fabian TC, Savage S, Holcomb JB, Scalea TM, Rasmussen TE. Blunt cerebrovascular injuries: Outcomes from the American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment (PROOVIT) multicenter registry. J Trauma Acute Care Surg 2021; 90:987-995. [PMID: 34016922 DOI: 10.1097/ta.0000000000003127] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Administering antithrombotics (AT) to the multiply injured patient with blunt cerebrovascular injury (BCVI) requires a thoughtful assessment of the risk of stroke and death associated with nontreatment. Large, multicenter analysis of outcomes stratified by injury grade and vessel injured is needed to inform future recommendations. METHODS Nine hundred and seventy-one BCVIs were identified from the PROspective Vascular Injury Treatment registry in this retrospective analysis. Using multivariate analysis, we identified predictors of BCVI-related stroke and death. We then stratified these risks by injury grade and vessel injured. We compared the risk of adverse outcomes in the nontreatment group with those treated with antiplatelet agents and/or anticoagulants. RESULTS Stroke was identified in 7% of cases. Overall mortality was 12%. Both increased with increasing BCVI grade. Treatment with ATs was associated with lower mortality and was not significantly affected by the choice of agent. Withholding ATs was associated with an increased risk of stroke and/or death across all subgroups (Grade I/II: odds ratio [OR], 4.66; 95% confidence interval [CI], 2.48-8.75; Grade III: OR, 7.0; 95% CI, 2.01-24.5; Grade IV: OR, 4.43; 95% CI, 1.76-11.1) even after controlling for covariates. Predictors of death included more severe trauma, Grade IV injury, and the occurrence of stroke. Arterial occlusion, hypotension, and endovascular intervention were significant predictors of stroke. Patients that experienced a BCVI-related stroke were at a 4.2× increased risk of death. The data set lacked the granularity necessary to evaluate AT timing or dosing regimen, which limited further analysis of stroke prevention strategies. CONCLUSION Stroke and death remain significant risks for all BCVI grades regardless of the vessel injured. Antithrombotics represent the only management strategy that is consistently associated with a lower incidence of stroke and death in all BCVI categories. In the multi-injured BCVI patient with a high risk of bleeding on anticoagulation, antiplatelet agents are an efficacious alternative. Given the 40% mortality rate in patients who survived their initial trauma and developed a BCVI-related stroke, nontreatment may no longer be a viable option. LEVEL OF EVIDENCE Epidemiological III; Therapeutic IV.
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