Neurovascular and tendon injuries due to ankle arthroscopy portals: a meta-analysis of interventional cadaveric studies

Neurovascular and tendon structures are considered at risk when performing ankle arthroscopy. Injury rate and distance from portals to such structures varied in the literature. The aim of this meta-analysis is to evaluate the injury risk of these structures in terms of proximity and injury prevalence. Thirteen studies including 184 cadaveric ankle arthroscopy procedures met the inclusion criteria. The antero-central portal exhibited the highest frequencies of nerve/vessel proximity and nerve/vessel missed injuries. Weighted mean distances were as follows: 2.76 ± 2.37 mm for the superficial fibular nerve (SFN) to the antero-lateral portal, 8.13 ± 2.45 mm for the saphenous nerve to the antero-medial portal, 2.1 ± 1.7 mm for the dorsalis pedis artery (DPA) to the antero-central (AC) portal, 6.84 ± 2.59 mm for the sural nerve to the postero-lateral portal. Distances to the postero-medial portal were 7.82 ± 2.98 and 11.03 ± 3.2 mm for the posterior tibial nerve and the posterior tibial artery, respectively. A total of 14 (10.3%) nerve injuries and 17 (12.5%) missed nerve injuries with a cumulative frequency of 22.8% of nerve structure at high risk. The SFN was the most vulnerable (10.3% of injury/missed injury), and it was the closest nerve to a portal. Vascular involvement consisted of 2 (1.5%) injuries and 12 (8.8%) missed injuries with the DPA being the most vulnerable (20%) through the AC portal. Tendon injuries were found in 8.7% procedure acts. The injury rates of extra-articular structures were found to be higher than previously reported in clinical literature. Apart from clinical studies, distance to portals and missed injuries of these structures could be evaluated. This cadaveric meta-analysis yielded more accurate results over the proximity and potential injury risk of ankle noble structure and should incite surgeons for more attention during portal placement. Such anatomical meta-analyses could offer an excellent statistical model of evidence synthesis when assessing injury risk in mini-invasive surgeries.

Profunda femoris artery injury caused by lesser trochanter fragment in intertrochanteric fracture: A case report

Vascular injuries following intertrochanteric fracture have been sporadically reported. Despite its rare occurrence, this complication can be potentially life and limb threatening. The authors report an unusual presentation of false aneurysm of profunda femoris artery following an intertrochanteric fracture with marked displacement of lesser trochanter fragment. The patient presented with thigh swelling and unexplainable dropped hematocrit. Surgical exploration and vascular repair were done. It is essential for the surgeon to be aware of possible associated vascular injuries in intertrochanteric fracture, particularly in fracture with lesser trochanter fragment.

ACR Appropriateness Criteria® Penetrating Neck Injury

In patients with penetrating neck injuries with clinical soft injury signs, and patients with hard signs of injury who do not require immediate surgery, CT angiography of the neck is the preferred imaging procedure to evaluate extent of injury. Other modalities, such as radiography and fluoroscopy, catheter-based angiography, ultrasound, and MR angiography have their place in the evaluation of the patient, depending on the specific clinical situation and question at hand. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Three-Dimensional Strain Measurements of a Tubular Elastic Model Using Tomographic Particle Image Velocimetry

The evaluation of strain induced in a blood vessel owing to contact with a medical device is of significance to examine the causes leading to vascular injury and rupture. The development of a method to assess strain in largely deformed elastic materials is expected. This study's scope was to measure strain in deformed tubular elastic mock vessels using tomographic particle image velocimetry (tomo-PIV), and to show the applicability of this measurement method by comparing the results with data derived from a finite element analysis (FEA). Strain distribution was calculated from the displacement distribution, which in turn was measured by tracking fluorescent 13 μm particles in a transparent tubular elastic model using tomo-PIV. The von Mises strain distribution was calculated for a model whose inner diameter was subjected to a pressure load, because of which it expanded from 25 to 27.5 mm, adjusting to the diameter change of a human aorta during heartbeat. An FEA simulating the experiment was also conducted. Three-dimensional strain was successfully measured by using the tomo-PIV method. The radial strain distribution in the model linearly decreased outward (from the its inner to its outer side), and the result was consistent with the data obtained from the FEA. The mean von Mises strain measured using tomo-PIV was comparable with that obtained from the FEA (tomo-PIV: 0.155, FEA: 0.156). This study demonstrates the feasibility of utilizing tomo-PIV to quantitatively assess the three-dimensional strain induced in largely deformed elastic models.

[Paresis of the brachial plexus after anterior shoulder luxation : Traumatic damage or compression due to hematoma?]

After traumatic anterior shoulder dislocation and self-reduction, the patient initially showed an inconspicuous clinical course. At the time of presentation in the emergency room the upper limb neurological status was reported to be normal. After discharge, paresis of the brachial plexus of the left arm occurred within 8 h. A subsequently performed computed tomography (CT) scan revealed a hematoma close to the brachial plexus, which was treated by surgical decompression and resulted in symptom relief. This case report describes a rare but significant complication after anterior shoulder dislocation, which should not be underestimated in the setting of a surgical emergency admission.

Management of knee dislocation prior to ligament reconstruction: What is the current evidence? Update of a universal treatment algorithm

Traumatic knee dislocation is a rare but potentially limb-threatening injury. Thus proper initial diagnosis and treatment up to final ligament reconstruction are extremely important and a precondition to successful outcomes. Reports suggest that evidence-based systematic approaches lead to better results. Because of the complexity of this injury and the inhomogeneity of related literature, there are still various controversies and knowledge gaps regarding decision-making and step-sequencing in the treatment of acute multi-ligament knee injuries and knee dislocations. The use of ankle-brachial index, routine or selective angiography, braces, joint-spanning or dynamic external fixation, and the necessity of initial ligament re-fixation during acute surgery constitutes current topics of a scholarly debate. The aim of this article was to provide a comprehensive literature review bringing light into some important aspects about the initial treatment of knee dislocation (vascular injury, neural injury, immobilization techniques) and finally develop an accurate data-based universal algorithm, enabling attending physicians to become more acquainted with the management of acute knee dislocation.

Mobilization of progenitor cells and assessment of vessel healing after second generation drug-eluting stenting by optical coherence tomography

Background

Bone marrow-derived progenitor cells likely contribute to both endothelial- and smooth muscle cell-dependent healing responses in stent-injured vessel sites. This study aimed to assess mobilization of progenitor cells and vessel healing after zotarolimus-eluting (ZES) and everolimus-eluting (EES) stents.

Methods and results

In 63 patients undergoing coronary stent implantation, we measured circulating CD34 + CD133 + CD45low cells and serum levels of biomarkers relevant to stem cell mobilization. In 31 patients of them, we assessed vessel healing within the stented segment using optical coherence tomography (OCT) imaging. The CD34 + CD133 + CD45low cells increased 68 ± 59% 7 days after bare metal stent (BMS), 10 ± 53% after ZES (P < 0.01 vs BMS), 3 ± 49% after EES (P < 0.001 vs BMS), compared with baseline. Percent change in CD34 + CD133 + CD45low cells was positively correlated with that in stromal cell-derived factor (SDF)-1α (R = 0.29, P = 0.034). Percentage of uncovered struts was higher in the EES group (14.4 ± 17.3%), compared with the BMS (0.7 ± 1.3, P < 0.01) and ZES (0.4 ± 0.5, P < 0.01) groups. The change in CD34 + CD133 + CD45low cells showed positive correlation with OCT-quantified mean neointimal area (R = 0.48, P < 0.01). Finally, circulating mononuclear cells obtained from 5 healthy volunteers were isolated to determine the effect of sirolimus, zotarolimus and everolimus on vascular cell differentiation. The differentiation of mononuclear cells into endothelial-like cells was dose-dependently suppressed by sirolimus, zotarolimus, and everolimus.

Conclusions

Mobilization of progenitor cells was suppressed, and differentiation of mononuclear cells into endothelial-like cells was inhibited, in association with increased number of uncovered stent struts, even after second generation drug-eluting stenting. These data suggest that new approaches are necessary to enhance stent healing.

Epigenetics and pathogenesis of systemic sclerosis; the ins and outs

The pathogenesis of many diseases is influenced by environmental factors which can affect human genome and be inherited from generation to generation. Adverse environmental stimuli are recognized through the epigenetic regulatory complex, leading to gene expression alteration, which in turn culminates in disease outcomes. Three epigenetic regulatory mechanisms modulate the manifestation of a gene, namely DNA methylation, histone changes, and microRNAs. Both epigenetics and genetics have been implicated in the pathogenesis of systemic sclerosis (SSc) disease. Genetic inheritance rate of SSc is low and the concordance rate in both monozygotic (MZ) and dizygotic (DZ) twins is little, implying other possible pathways in SSc pathogenesis scenario. Here, we provide an extensive overview of the studies regarding different epigenetic events which may offer insights into the pathology of SSc. Furthermore, epigenetic-based interventions to treat SSc patients were discussed.

Pit Bull attack causing limb threatening vascular trauma -A case series

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Canine attacks by Pit Bull Terriers and Rottweiler’s can occur at any age and in any anatomical area of the body particularly the limbs.

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Any attack by these large canines can result in limb loss or loss of life.

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The most common injury to a vessel was an occlusion, although penetrating injuries usually cause a puncture or laceration, the blunt injury may be the more clinically significant one.

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Immediate surgical exploration is required to prevent catastrophic outcomes, especially limb loss, since arterial thrombosis is noted to be one of the most common finding in crush injuries.

Introduction

Non-fatal human dog bites are commonplace amongst animal attacks on human beings and these present with mainly skin and soft tissue injuries. However, they can also present with life threatening head and neck injuries, massive soft tissue trauma, as well as combined orthopedic and vascular extremity injuries where a high possibility of limb loss exists.

Presentation of cases

We present two adult dog bite victims with multiple bites inflicted by large canines identified as Pit-Bull Terriers. They were presented with deep lacerations to the axillary area resulting in limb ischemia and loss of upper limb pulses. The right axillary artery was crushed in both patients whilst the axillary vein was lacerated in one. The vessels were repaired; the wounds debrided and both limbs were salvaged.

Discussion

Canine attacks by Pit Bull Terriers and Rottweiler’s can occur at any age and in any anatomical area of the body particularly the limbs. Injuries involving the extremities presenting with no pulses or pulsatile bleeding demand an urgent exploration as any undue delay is intolerable especially if there are bony injuries like fractures or fracture/dislocation. All patients with complex neurovascular injuries should be managed by a multidisciplinary team for an optimal outcome.

Conclusion

Attacks by Pit Bull Terriers are more likely to cause severe morbidity than other breeds of dogs. Immediate surgical exploration is required to prevent catastrophic outcomes, especially limb loss. Stronger animal control laws, public education and responsible dog ownership may reduce deaths from these canines.

Periadventitial local drug delivery to target restenosis

The adventitia functions as a dynamic compartment for cell trafficking into and out of the artery wall, and communicates with medial and intimal cells. The resident cells in the tunica adventitia play an integral role in the regulation of vessel wall structure, repair, tone, and remodeling. Following injury to the vascular wall, adventitial fibroblasts are activated, which proliferate and differentiate into migratory myofibroblasts, and initiate inflammation through the secretion of soluble factors such as chemokines, cytokines, and adhesion molecules. The secreted factors subsequently promote leukocyte recruitment and extravasation into the media and intima. The adventitia generates reactive oxygen species and growth factors that participate in cell proliferation, migration, and hypertrophy, resulting in intimal thickening. The adventitial vasa vasorum undergoes neovascularization and serves as a port of entry for the delivery of inflammatory cells and resident stem/progenitor cells into the intima, and thus facilitates vascular remodeling. This review highlights the contribution of multilineage cells in the adventitia along with de-differentiated smooth muscle-like cells to the formation of neointimal hyperplasia, and discusses the potential of periadventitial local drug delivery for the prevention of vascular restenosis.

P2X7R antagonism after subfailure overstretch injury of blood vessels reverses vasomotor dysfunction and prevents apoptosis

Human saphenous vein (HSV) is harvested and prepared prior to implantation as an arterial bypass graft. Injury and the response to injury from surgical harvest and preparation trigger cascades of molecular events and contribute to graft remodeling and intimal hyperplasia. Apoptosis is an early response after implantation that contributes the development of neointimal lesions. Here, we showed that surgical harvest and preparation of HSV leads to vasomotor dysfunction, increased apoptosis and downregulation of the phosphorylation of the anti-apoptotic protein, Niban. A model of subfailure overstretch injury in rat aorta (RA) was used to demonstrate impaired vasomotor function, increased extracellular ATP (eATP) release, and increased apoptosis following pathological vascular injury. The subfailure overstretch injury was associated with activation of p38 MAPK stress pathway and decreases in the phosphorylation of the anti-apoptotic protein Niban. Treatment of RA after overstretch injury with antagonists to purinergic P2X7 receptor (P2X7R) antagonists or P2X7R/pannexin (PanX1) complex, but not PanX1 alone, restored vasomotor function. Inhibitors to P2X7R and PanX1 reduced stretch-induced eATP release. P2X7R/PanX1 antagonism led to decrease in p38 MAPK phosphorylation, restoration of Niban phosphorylation and increases in the phosphorylation of the anti-apoptotic protein Akt in RA and reduced TNFα-stimulated caspase 3/7 activity in cultured rat vascular smooth muscle cells. In conclusion, inhibition of P2X7R after overstretch injury restored vasomotor function and inhibited apoptosis. Treatment with P2X7R/PanX1 complex inhibitors after harvest and preparation injury of blood vessels used for bypass conduits may prevent the subsequent response to injury that lead to apoptosis and represents a novel therapeutic approach to prevent graft failure.

Management of Major Vascular Injuries: Neck, Extremities, and Other Things that Bleed

Vascular injuries represent a significant burden of mortality and disability. Blunt injuries to the neck vessels can present with signs of stroke either immediately or in a delayed fashion. Most injuries are detected with computed tomography angiography and managed with either antiplatelet medications or anticoagulation. In contrast, patients with penetrating injuries to the neck vessels require airway management, hemorrhage control, and damage control resuscitation before surgical repair. The keys to diagnosis and management of peripheral vascular injury include early recognition of the injury; hemorrhage control with direct pressure, packing, or tourniquets; and urgent surgical consultation.

Management of major vascular injury during pedicle screw instrumentation of thoracolumbar spine

OBJECTIVES

Vascular injury is a rare complication of spinal instrumentation. Presentation can vary from immediate hemorrhage to pseudoaneurysm formation. In the literature, surgical approach to repair has varied based on anatomy, acuity of diagnosis, infection, and available technology. In this manuscript, we aim to describe our institutional experience with vascular injuries in thoraco-lumbar spine surgery.

PATIENTS AND METHODS

We report our institutional experience of three cases of vascular injury secondary to pedicle screw misplacement and their management, as well as a review of the literature.

RESULTS

The first case had a history of previous instrumentation and presented with back pain and fever. The patient was taken for instrumentation exploration via a posterior approach. Aortic violation was discovered at T6 intraoperatively during instrumentation removal and the patient underwent emergent endovascular repair. The second case presented with chronic back pain after multiple prior posterior fusions and CT angiogram showing screw perforation on the aorta at T10. The patient underwent elective endovascular repair with synchronous removal of the instrumentation. The third case presented with radicular leg pain 6 months after L4-S1 posterior lumbar interbody fusion, with CT scan demonstrating the left S1 screw abutting the L5 nerve root and common iliac vein. The patient underwent elective instrumentation revision with intraoperative venography.

CONCLUSION

Major vascular injury is a known complication of spinal surgery, especially if it involves instrumentation with pedicle screws. Treatment approach has evolved with the advancement of endovascular technology; however, open surgery remains an option when anatomy or infection is prohibitive. In the elective setting, preoperative planning with attention to surgical approach, positioning, and contingencies, should occur in a multidisciplinary fashion. Repair with an aortic stent-graft cuff may minimize unnecessary coverage of the descending thoracic aorta and intercostal arteries.

Surgical management of posterior knee dislocation associated with extensor apparatus rupture

OBJECTIVE

The purpose of this study was to report the clinical and functional results of patients who underwent surgical management for posterior knee dislocation associated with extensor apparatus rupture.

INTRODUCTION

Posterior knee dislocations associated with extensor apparatus ruptures are defined as rare but complicated injuries, which are difficult to return to the level of activity prior to the injury. The study demonstrated a hypothesis that good knee stability and early gain of range of motion could be achieved with deliberate design of the treatment protocol and proper application of the instruments.

METHODS

Fifteen patients with posterior knee dislocations associated with extensor apparatus ruptures were evaluated after reduction and repair of extensor apparatus. Following that, multiple-ligament reconstruction in association with use of a lateral knee-spanning external fixator was applied for at least six weeks. Ligament reconstructions were performed using allografts. Range of motion and knee stability were both measured at each follow-up evaluation at a mean time of 36months. The assessment was made using the Lysholm Knee Scoring Scale.

RESULTS

The mean Lysholm scale score was 87.6 (range 73-95), with excellent in 11 cases, good in two, and fair in two. In the final evaluation, the range of motion was a mean range of 123.4° (range 100-135).

CONCLUSION

The use of a lateral knee-spanning external fixator ensured the safety of repaired vessels, knee stability after reduction, and early rehabilitation with range of motion.

Liver transplantation in the treatment of severe iatrogenic liver injuries

The place of liver transplantation in the treatment of severe iatrogenic liver injuries has not yet been widely discussed in the literature. Bile duct injuries during cholecystectomy represent the leading cause of liver transplantation in this setting, while other indications after abdominal surgery are less common. Urgent liver transplantation for the treatment of severe iatrogenic liver injury may-represent a surgical challenge requiring technically difficult and time consuming procedures. A debate is ongoing on the need for centralization of complex surgery in tertiary referral centers. The early referral of patients with severe iatrogenic liver injuries to a tertiary center with experienced hepato-pancreato-biliary and transplant surgery has emerged as the best treatment of care. Despite widespread interest in the use of liver transplantation as a treatment option for severe iatrogenic injuries, reported experiences indicate few liver transplants are performed. This review analyzes the literature on liver transplantation after hepatic injury and discusses our own experience along with surgical advances and future prospects in this uncommon transplant setting.

Penetrating Vascular Injury: Diagnosis and Management Updates

Penetrating vascular injury is becoming increasingly common in the United States and abroad. Much of the current research and treatment is derived from wartime and translation to the civilian sector has been lacking. Penetrating vascular injury can be classified as extremity, junctional, or noncompressible. Diagnosis can be obvious but at other times subtle and difficult to diagnose. Although there are numerous modalities, computed tomography angiography is the diagnostic study of choice. It is hoped that care will be improved by using an algorithmic approach integrating experience from military and civilian research.

Hereditary multiple exostoses as a novel cause of bilateral popliteal artery aneurysms in the elderly

Hereditary multiple exostoses (HME) is a genetic condition characterized by the development of multiple osteochondromas during childhood and adolescence. On rare occasions, these bony tumors can be associated with vascular injury, most commonly involving the popliteal artery. Such patients typically present with vascular complications in adolescence and young adulthood. We report an autopsy study of an elderly man who presented with bilateral popliteal artery pseudoaneurysms in the setting of HME at age 81. This is the oldest patient presenting with a vascular complication due to HME reported to date, as well as the only known case of bilateral popliteal pseudoaneurysms caused by HME. This is also the only autopsy study of this vascular complication so far reported. Our case illustrates that vascular complications from HME can occur even in the elderly, and may show bilateral involvement.

Resolution of vascular injury: Specialized lipid mediators and their evolving therapeutic implications

Acute vascular injury occurs in a number of important clinical contexts, including spontaneous disease-related events (e.g. plaque rupture, thrombosis) and therapeutic interventions such as angioplasty, stenting, or bypass surgery. Endothelial cell (EC) disruption exposes the underlying matrix, leading to a rapid deposition of platelets, coagulation proteins, and leukocytes. A thrombo-inflammatory response ensues characterized by leukocyte recruitment, vascular smooth muscle cell (VSMC) activation, and the elaboration of cytokines, reactive oxygen species and growth factors within the vessel wall. A resolution phase of vascular injury may be described in which leukocyte efflux, clearance of debris, and re-endothelialization occurs. VSMC migration and proliferation leads to the development of a thickened neointima that may lead to lumen compromise. Subsequent remodeling involves matrix protein deposition, and return of EC and VSMC to quiescence. Recent studies suggest that specialized pro-resolving lipid mediators (SPM) modulate key aspects of this response, and may constitute an endogenous homeostatic pathway in the vasculature. SPM exert direct effects on vascular cells that counteract inflammatory signals, reduce leukocyte adhesion, and inhibit VSMC migration and proliferation. These effects appear to be largely G-protein coupled receptor-dependent. Across a range of animal models of vascular injury, including balloon angioplasty, bypass grafting, and experimental aneurysm formation, SPM accelerate repair and reduce lesion formation. With bioactivity in the pM-nM range, a lack of discernible cytotoxicity, and a spectrum of vasculo-protective properties, SPM represent a novel class of vascular therapeutics. This review summarizes current research in this field, including a consideration of critical next steps and challenges in translation.

Proximal humerus fracture dislocation leading to axillary artery injury in an young adult: Case report of an unusual presentation

Proximal humerus fractures constitute five percent of all fracture cases. Though rare, severely comminuted proximal humerus fractures can cause injury to neurovascular structure. Majority of these injuries reported in literature were in elderly age group from low velocity injury owing to loss of elasticity of vessel wall. We report a case of proximal humerus fracture dislocation associated with axillary artery injury in a young male due to fall of heavy iron object. Timely exploration and removal of impinging bone fragment restored the blood supply. The purpose of this report is to heighten the clinical suspicion of the vascular injury in patients with proximal humerus fracture dislocations in all age groups.

The incidence of life threatening iatrogenic vessel injury following closed or open reduction and internal fixation of intertrochanteric femoral factures

AIM OF THE STUDY

Bleeding due to a vascular injury is a possible life-threatening complication of intertrochanteric femoral fracture internal fixation. Our goals were to find the current incidence of these events, and to describe the reasons, the presentation, and the treatment options.

METHOD

We conducted a retrospective record review of 1,469 patients who were operated upon at our institution due to AO31A femoral fractures from 2011 through 2015 and were treated with closed reduction and internal fixation.

RESULTS

Three patients were diagnosed with iatrogenic vascular bleeding, which constitute an incidence of 0.2%. The vascular injuries were detected as deep femoral artery bleeding adjacent to the distal locking screws. The patients were treated with ultrasound guided thrombin injection, endovascular coil embolization or with no endovascular intervention.

DISCUSSION

Vascular injuries are caused mainly by perforating a vessel while drilling the distal locking screw holes. A high level of suspicion and immediate imaging work-up are mandatory.

CONCLUSIONS

A vascular injury due to internal fixation of a proximal AO31A femoral fracture is a rare complication.

Role of Adipokines in Cardiovascular Disease

Cardiovascular disease (CVD) is the greatest cause of death, accounting for nearly one-third of all deaths worldwide. The increase in obesity rates over 3 decades is widespread and threatens the public health in both developed and developing countries. Obesity, the excessive accumulation of visceral fat, causes the clustering of metabolic disorders, such as type 2 diabetes, dyslipidemia, and hypertension, culminating in the development of CVD. Adipose tissue is not only an energy storage organ, but an active endocrine tissue producing various biologically active proteins known as adipokines. Since leptin, a central regulator of food intake and energy expenditure, was demonstrated to be an adipose-specific adipokine, attention has focused on the identification and characterization of unknown adipokines to clarify the mechanisms underlying obesity-related disorders. Numerous adipokines have been identified in the past 2 decades; most adipokines are upregulated in the obese state. Adipokines such as tumor necrosis factor (TNF)-α, interleukin (IL)-6, IL-1β, and resistin are pro-inflammatory, and exacerbate various metabolic and cardiovascular diseases. However, a small number of adipokines, including adiponectin, are decreased by obesity, and generally exhibit antiinflammatory properties and protective functions against obesity-related diseases. Collectively, an imbalance in the production of pro- and antiinflammatory adipokines in the obese condition results in multiple complications. In this review, we focus on the pathophysiologic roles of adipokines with cardiovascular protective properties.

Repetitive Blunt Trauma and Arterial Injury in the Hand

INTRODUCTION/PURPOSE

Arterial injury in the hand is most often due to repetitive blunt trauma. Although not always associated with significant impairment, it may cause serious ischemic damage or considerable disability. As a cause of digital ischemia, the frequency of this disorder is widely under appreciated. This study reviews the clinical and angiographic features of this condition.

MATERIALS/METHODS

An extensive literature review combined with the authors experience with arterial injury in the hand due to repetitive blunt hand trauma is summarized with emphasis on mechanisms of injury and pathologic changes to explain the angiographic findings and clinical presentations.

RESULTS

Angiographic findings are related to severity of injury and underlying changes in the arterial wall. The clinical presentation varies from asymptomatic to digital necrosis and gangrene, related to severity of arterial injury, collateral circulation, and the highly variable arterial anatomy in the hand.

CONCLUSION

Early recognition is important because compared to many other causes of digital ischemia in the upper extremities, traumatic arterial injury is frequently readily treatable. Angiographic findings and clinical presentation are often characteristic. The diagnosis should not be based on a clear history of repetitive hand trauma since the patient may be unaware of this occurrence.

Endovascular management for peripheral arterial trauma: The new norm?

BACKGROUND

Endovascular therapy is well studied in atraumatic conditions; and there appears to be a growing interest in its application to traumatic injuries. The objective of this study is to compare open and endovascular techniques in the management of peripheral arterial trauma.

METHODS

This is a retrospective review of patients admitted to a Level I Trauma Center sustaining injuries to the subclavian, axillary, superficial femoral, and popliteal arteries. Demographics, surgical interventions, complications, and clinical outcomes were evaluated in patients requiring open or endovascular repair between 2009 and 2015.

RESULTS

Sixty-eight patients with 70 total arterial injuries were identified. There were 10 subclavian, 14 axillary, 15 superficial femoral, and 31 popliteal artery injuries. Endovascular (n=20) compared to open repairs (n=50) were more commonly performed: by vascular surgeons (90% vs. 54%, p=0.01); in older patients (median age: 38 years vs. 25, p=0.01); primarily involving upper extremity injuries (60% vs. 24%, p=0.01). Furthermore, endovascular repairs less commonly required fasciotomy (15% vs. 46%, p=0.03) and trended towards lower transfusion requirements (50% vs. 77%, p=0.06). Patients undergoing open repair had lower pre-hospital systolic blood pressures (110 vs. 120, p=0.03) and lower initial hematocrit (31.5 vs. 36.2, p=0.02). However, outcomes between groups were trending higher in the endovascular group with respect to limb salvage rates at discharge (94% vs. 89%), median length of stay (14days vs. 9), and median follow-up (288days vs. 92) compared to the open group, but the data were not statistically significant. There was increasing utilization of endovascular repair over time (7% of total procedures in 2009; 50% in 2014).

CONCLUSIONS

Overall, endovascular and open techniques were not statistically different in early outcomes. Endovascular therapy appears to provide some advantage when it comes to: challenging anatomy, decreasing blood product utilization, and minimizing physiologic derangement. However, patients with injuries resulting in free hemorrhage or significant external blood loss may still be best served with open repair. Despite this, given the increasing use of endovascular techniques, close collaboration is needed between trauma and endovascular specialists to properly select the optimal management for patients with peripheral arterial trauma.

[Acute therapeutic measures for limb salvage Part 1 : Haemorrhage control, emergency revascularization, compartment syndrome]

The primary care of Gustilo-Anderson type IIIC extremity injuries with relevant vessel lacerations is decisive for the success of a limb salvage procedure. This article shall present substantial emergency procedures for the salvage of the nutritive perfusion of a mangled extremity, based on the current literature. After provisory control of a peripheral haemorrhage (e. g. by manual pressure or tourniquet), an immediate decision must be made about the kind of emergency revascularization to be implemented as the limb salvage procedure. Here, the temporary intravascular shunt will be the fastest technique that can ensure a sufficient tissue perfusion in the case of vessel lacerations. Regarding the treatment of a fracture versus perfusion recovery, a shortening of ischemia time should have priority over fracture stabilization.If an acute compartment syndrome is suspected, a documented monitoring has to be performed in the limb salvage situation for 24 hours with clinical controls every 4 hours. Disproportional pain that does not respond to analgesics, and passive muscle stretching pain can be seen as cardinal symptoms. The positive predictive value of clinical findings is <15 %. During the observation period with an impending but not manifest compartment syndrome, an elevation of the extremity above heart level or its cooling are contraindicated. An intracompartmental pressure measurement is the most important instrument-based supplemental diagnostic method. The open fasciotomy of the affected compartments is the only causal therapy and should be performed as fast as possible. A decision against fasciotomy in cases of non-explicit clinical signs should not be made without a documented intracompartmental pressure measurement.

A numerical study on the application of the functionally graded materials in the stent design

Undesirable deformation of the stent can induce a significant amount of injure not only to the blood vessel but also to the plaque. The objective of this study was to reduce/minimize these undesirable deformations by the application of Functionally Graded Materials (FGM). To do this, Finite Element (FE) method was employed to simulate the expansion of a stent and the corresponding displacement of the stenosis plaque. Three hyperelastic plaque types as well as five elastoplastic stents were simulated. Dogboning, foreshortening, maximum stress in the plaque, and the pressure which is needed to fully expand the stent for different stent materials, were acquired. While all FGMs had lower dogboning in comparison to the stents made of the uniform materials, the stent with the lowest heterogeneous index displayed the lowest amount of dogboning. Steel stent showed the lowest foreshortening and fully expansion pressure but the difference was much lower than that the one for dogboning. Therefore, the FGM with the heterogeneous index of 0.5 is expected to exhibit the most suitable results. In addition, the results revealed that the material parameters has crucial effects on the deformation of the stent and, as a result, as a design point of view the FGM parameters can be tailored to achieve the goal of the biomechanical optimization.

Adenosine triphosphate as a molecular mediator of the vascular response to injury

BACKGROUND

Human saphenous veins used for arterial bypass undergo stretch injury at the time of harvest and preimplant preparation. Vascular injury promotes intimal hyperplasia, the leading cause of graft failure, but the molecular events leading to this response are largely unknown. This study investigated adenosine triphosphate (ATP) as a potential molecular mediator in the vascular response to stretch injury, and the downstream effects of the purinergic receptor, P2X7R, and p38 MAPK activation.

MATERIALS AND METHODS

A subfailure stretch rat aorta model was used to determine the effect of stretch injury on release of ATP and vasomotor responses. Stretch-injured tissues were treated with apyrase, the P2X7R antagonist, A438079, or the p38 MAPK inhibitor, SB203580, and subsequent contractile forces were measured using a muscle bath. An exogenous ATP (eATP) injury model was developed and the experiment repeated. Change in p38 MAPK phosphorylation after stretch and eATP tissue injury was determined using Western blotting. Noninjured tissue was incubated in the p38 MAPK activator, anisomycin, and subsequent contractile function and p38 MAPK phosphorylation were analyzed.

RESULTS

Stretch injury was associated with release of ATP. Contractile function was decreased in tissue subjected to subfailure stretch, eATP, and anisomycin. Contractile function was restored by apyrase, P2X7R antagonism, and p38-MAPK inhibition. Stretch, eATP, and anisomycin-injured tissue demonstrated increased phosphorylation of p38 MAPK.

CONCLUSIONS

Taken together, these data suggest that the vascular response to stretch injury is associated with release of ATP and activation of the P2X7R/P38 MAPK pathway, resulting in contractile dysfunction. Modulation of this pathway in vein grafts after harvest and before implantation may reduce the vascular response to injury.

The FAST D protocol: a simple method to rule out traumatic vascular injuries of the lower extremities

Background

The aim of this study is to assess the accuracy of a Fast Doppler protocol for the examination of an injured lower limb, namely 2-Point Fast Doppler (2PFD), in order to rapidly triage arterial lesions after penetrating trauma.

Methods

The presence of flow and the aspects of the Doppler waveform of the dorsalis pedis artery (DPA) and posterior tibial artery (PTA) of the injured lower limb (2PFD) were evaluated immediately before the execution of a standardized Color Duplex Doppler (SD) evaluation in 149 limbs of 140 patients with gunshot penetrating injuries. We considered 2PFD normal exams as the ones with triphasic patterns in both the DPA and PTA, and 2PFD pathologic exams as the ones with absent, biphasic, or monophasic flow patterns in the DPA and/or PTA. 2PFD data were then analyzed to assess accuracy variables, using SD results as matching test reference. According to the trauma center standard protocols, SD positive cases underwent also angiography and surgical exploration, whose findings were used to further match the 2PFD specificity.

Results

The 2PFD protocol showed a sensitivity of 100%, and a specificity of 100% compared with the SD, in the diagnostic workup of arterial injuries of the lower limbs after penetrating trauma. Furthermore, all the pathologic cases that resulted in all true positives (TP), compared with SD, were confirmed as TP also when matched with the angiography evaluation results.

Conclusions

The 2PFD protocol can rapidly identify arterial flow and differentiate between normal and pathologic spectral Doppler analyses in distal arteries. The presence of the normal triphasic flows in DPA and PTA is as sensitive as the standardized Color Doppler Duplex assessment of the entire limb in ruling out arterial lesions in lower-limb penetrating trauma. The absence of flow or the presence of a biphasic or monophasic pathologic flow in DPA and PTA is pathologic and should be always followed by further investigation. 2PFD is faster and easier to perform compared with the SD approach. It could become a new first-line screening technique, both in pre-hospital and hospital critical scenarios, particularly in contexts where advanced diagnostic performance is limited by time concerns or scarce resources.

Occult external iliac vein injury after anterior dislocation of the sacroiliac joint in adult patient

Anterior dislocation of the sacroiliac joint, characterized by dislocation of the ilium anterior to the sacrum, is a subtype of complete posterior pelvic ring disruption. This injury occurs mostly in children. We present an adult patient with anterior dislocation of the sacroiliac joint. It was associated with numerous complications. To the best of our knowledge, it is only the second case reported in the literature.

Induced Pluripotent Stem Cell-Derived Endothelial Cells Overexpressing Interleukin-8 Receptors A/B and/or C-C Chemokine Receptors 2/5 Inhibit Vascular Injury Response

Recruitment of neutrophils and monocytes/macrophages to the site of vascular injury is mediated by binding of chemoattractants to interleukin (IL) 8 receptors RA and RB (IL8RA/B) C‐C chemokine receptors (CCR) 2 and 5 expressed on neutrophil and monocyte/macrophage membranes. Endothelial cells (ECs) derived from rat‐induced pluripotent stem cells (RiPS) were transduced with adenovirus containing cDNA of IL8RA/B and/or CCR2/5. We hypothesized that RiPS‐ECs overexpressing IL8RA/B (RiPS‐IL8RA/B‐ECs), CCR2/5 (RiPS‐CCR2/5‐ECs), or both receptors (RiPS‐IL8RA/B+CCR2/5‐ECs) will inhibit inflammatory responses and neointima formation in balloon‐injured rat carotid artery. Twelve‐week‐old male Sprague‐Dawley rats underwent balloon injury of the right carotid artery and intravenous infusion of (a) saline vehicle, (b) control RiPS‐Null‐ECs (ECs transduced with empty virus), (c) RiPS‐IL8RA/B‐ECs, (d) RiPS‐CCR2/5‐ECs, or (e) RiPS‐IL8RA/B+CCR2/5‐ECs. Inflammatory mediator expression and leukocyte infiltration were measured in injured and uninjured arteries at 24 hours postinjury by enzyme‐linked immunosorbent assay (ELISA) and immunohistochemistry, respectively. Neointima formation was assessed at 14 days postinjury. RiPS‐ECs expressing the IL8RA/B or CCR2/5 homing device targeted the injured arteries and decreased injury‐induced inflammatory cytokine expression, neutrophil/macrophage infiltration, and neointima formation. Transfused RiPS‐ECs overexpressing IL8RA/B and/or CCR2/5 prevented inflammatory responses and neointima formation after vascular injury. Targeted delivery of iPS‐ECs with a homing device to inflammatory mediators in injured arteries provides a novel strategy for the treatment of cardiovascular diseases. Stem Cells Translational Medicine2017;6:1168–1177

Point-of-care ultrasound and Doppler ultrasound evaluation of vascular injuries in penetrating and blunt trauma

BACKGROUND

The aim of this study is to describe point-of-care ultrasound and Color flow Duplex Doppler characteristics of penetrating and blunt trauma-related vascular injuries of the limbs and neck.

METHODS

Penetrating and blunt trauma-related vascular injuries such as vein disruption, intimal flap, deep vein thrombosis, arterial dissection, pseudoaneurysm, and arteriovenous fistulae are discussed in this manuscript. Images of the most significant lesions of our personal clinical experience are presented to illustrate point-of-care ultrasound and Color flow Duplex Doppler ultrasound findings.

RESULTS

Penetrating and blunt trauma-related vascular injuries represent a big challenge. While patients with hard signs of arterial damage must be sent immediately to surgical exploration, when there are soft signs or no clear signs of vascular injury at the physical examination, and the patient is stable, imaging investigation and observation can be useful in the diagnosis and management of these patients. Although angiography is the gold standard of the imaging methods, point-of-care ultrasound and Color flow Duplex Doppler ultrasound are widely available, cheaper, noninvasive, and faster to obtain. They can provide bedside valuable information for the identification of some vascular injuries allowing to an integrated management of the trauma patient, enriched by the use of ultrasound.

CONCLUSIONS

Point-of-care ultrasound and Color flow Duplex Doppler examination are increasingly used in the decision making process of trauma-related vascular injuries.

Unliganded estrogen receptor alpha regulates vascular cell function and gene expression

The unliganded form of the estrogen receptor is generally thought to be inactive. Our prior studies, however, suggested that unliganded estrogen receptor alpha (ERα) exacerbates adverse vascular injury responses in mice. Here, we show that the presence of unliganded ERα decreases vascular endothelial cell (EC) migration and proliferation, increases smooth muscle cell (SMC) proliferation, and increases inflammatory responses in cultured ECs and SMCs. Unliganded ERα also regulates many genes in vascular ECs and mouse aorta. Activation of ERα by E2 reverses the cell physiological effects of unliganded ERα, and promotes gene regulatory effects that are predicted to counter the effects of unliganded ERα. These results reveal that the unliganded form of ERα is not inert, but significantly impacts gene expression and physiology of vascular cells. Furthermore, they indicate that the cardiovascular protective effects of estrogen may be connected to its ability to counteract these effects of unliganded ERα.

Protective effects of molecular hydrogen on steroid-induced osteonecrosis in rabbits via reducing oxidative stress and apoptosis

Background

The objective of this study was to investigate the protective effects of molecular hydrogen, a novel and selective antioxidant, on steroid-induced osteonecrosis (ON) in a rabbit model.

Methods

Sixty rabbits were randomly divided into two groups (model group and hydrogen group). Osteonecrosis was induced according to an established protocol of steroid-induced ON. Rabbits in the hydrogen group were treated with intraperitoneal injections of molecular hydrogen at 10 ml/kg body weight for seven consecutive days. Plasma levels of total cholesterol, triglycerides, soluble thrombomodulin(sTM), glutathione(GSH) and malondialdehyde(MDA) were measured before and after steroid administration. The presence or absence of ON was examined histopathologically. Oxidative injury and vascular injury were assessed in vivo by immunohistochemical staining of 8-hydoxy-2-deoxyguanosine(8-OHdG) and MDA, and ink artery infusion angiography. The terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) assays were performed to measure apoptosis.

Results

The incidence of steroid-induced ON was significantly lower in hydrogen group (28.6%) than that in model group (68.0%). No statistically differences were observed on the levels of total cholesterol and triglycerides. Oxidative injury, vascular injury and apoptosis were attenuated in the hydrogen group compared with those in the model group in vivo.

Conclusions

These results suggested that molecular hydrogen prevents steroid-induced osteonecrosis in rabbits by suppressing oxidative injury, vascular injury and apoptosis.

Anterior tibial artery pseudoaneurysm due to interlocking bolt of tibial nail: A case report and review

Vascular injuries associated with the tibial nailing have been reported in few case reports. We here report a unique case of anterior tibial artery (ATA) pseudoaneurysm caused by the second proximal coronal interlocking bolt. We found that the position of interlocking bolts on the nail brings them very close to the anatomical positions of arteries in leg. The reports of ATA injury by interlocking bolts highlight the need for reconsidering the nail design and screw hole positions.

Closure Devices for Iatrogenic Thoraco-Cervical Vascular Injuries

Introduction

The unintentional arterial placement of a central venous line can have catastrophic complications. The purpose of this systematic review is to assess and analyse the available evidence regarding the use of the various vascular closure devices (VCDs) for the management of iatrogenic thoraco-cervical arterial injuries (ITCAI).

Methods

A systematic review was performed according to PRISMA guidelines.

Results

Thirty-two relevant case series and case reports were identified with a total of 69 patients having being studied. In the majority of the studies, plug-based VCDs were used (81%) followed by suture-based devices (19%). The majority of studies reported successful outcomes from the use of VCDs in terms of achieving immediate haemostasis without any acute complications. Long-term follow-up data were only available in nine studies with only one case of carotid pseudoaneurysm being reported after 1-month post-procedure. All other cases had no reported long-term complications. Five studies performed direct or indirect comparisons between VCDs and other treatments (open surgery or stent grafting) suggesting no significant differences in safety or effectiveness.

Conclusion

Although there is limited evidence, VCDs appear to be safe and effective for the management of ITCAIs. Further research is warranted regarding the effectiveness of this approach in comparison to surgery and in order to identify those patients who are more likely to benefit from this minimally invasive approach.

White Matter Hyperintensities in Older Adults and Motoric Cognitive Risk Syndrome

INTRODUCTION

Motoric cognitive risk (MCR) syndrome is a recently described pre-dementia syndrome characterized by slow gait and cognitive complaints that has been implicated as a predictor of cognitive decline and dementia in older adults. Previous work suggests that cerebrovascular disease is associated with MCR. White matter hyperintensities (WMH) are postulated to be a product of cerebrovascular disease, and have been associated with impaired mobility and impaired cognition. This study aimed to determine if MCR is associated with regional WMH.

METHODS

Two cross-cultural cohorts of non-demented older adults were examined: 174 from a French memory clinic (62.1% male, mean age 70.7 ± 4.3 years) and 184 from an Indian community-dwelling cohort (55.4% male, mean age 66.2 ± 5.2 years). Participants were evaluated for slow gait, cognitive complaints, and regional WMH via MRI (fluid attenuated inversion recovery) FLAIR sequence.

RESULTS

Overall, 20.7% of participants met criteria for MCR, and 72.9% of participants had WMH on FLAIR. WMH in the frontal, parieto-occipital, temporal, basal ganglia, cerebellum, or brainstem were not associated with MCR in either of the two cohorts.

CONCLUSION

WMH was not significantly associated with MCR in this studied sample of participants, suggesting that other cerebrovascular pathophysiological mechanisms, or combination of mechanisms, might underlie MCR.

Radial artery vasomotor function following transradial cardiac catheterisation

Aims

To determine the reproducibility of flow-mediated dilation (FMD) and nitrate-mediated dilation (NMD) in the assessment of radial artery vasomotor function, and to examine the effect of transradial catheterisation on radial artery injury and recovery.

Methods

Radial artery FMD and NMD were examined in 20 volunteers and 20 patients on four occasions (two visits at least 24 hours apart, with two assessments at each visit). In a further 10 patients, radial artery FMD was assessed in the catheterised arm prior to, at 24 hours and 3 months following cardiac catheterisation.

Results

There were no differences in baseline radial artery diameter (2.7±0.4 mm vs 2.7±0.4 mm), FMD (13.4±6.4 vs 12.89±5.5%) or NMD (13.6±3.8% vs 10.1±4.3%) between healthy volunteers and patients (p>0.05 for all comparisons). Mean differences for within and between day FMD were 2.53% (95% CIs −15.5% to 20.5%) and −4.3% (−18.3% to 9.7%) in patients. Compared to baseline, radial artery FMD was impaired at 24 hours (8.7±4.1% vs 3.9±2.9%, p=0.015) but not 3 months (8.7±4.1% vs 6.2±4.4, p=0.34) following transradial catheterisation.

Conclusions

Radial FMD is impaired early after transradial catheterisation but appears to recover by 3 months. While test–retest variability was demonstrated, our findings suggest that transradial access for cardiac catheterisation may afford a potential model of vascular injury and repair in vivo in man.

Complication Avoidance in Endoscopic Skull Base Surgery

Endoscopic endonasal approaches to the skull base pathology have developed and evolved dramatically over the past 2 decades, particularly with collaboration between neurosurgery and otolaryngology physicians. These advances have increased significantly the use of such approaches beyond just resection of pituitary adenomas, including a variety of skull base pathologies. As the field has evolved, so has our understanding of the complications accompanying endoscopic skull base surgery, as well as techniques to both avoid and manage these complications. These are discussed here.

Neurological outcomes following iatrogenic vascular injury during posterior atlanto-axial instrumentation

BACKGROUND

Iatrogenic vascular injury is a feared complication of posterior atlanto-axial instrumentation. A better understanding of clinical outcome and management options following this injury will allow surgeons to better care for these patients. The object of the study was to systematically review the neurologic outcomes after iatrogenic vascular injury during atlanto-axial posterior instrumentation.

METHODS

We performed a systematic review of the Medline database following PRISMA guidelines. In our analysis, we included any retrospective cohort studies, prospective cohort studies, case reports, cases series, or systematic reviews with patients who had undergone posterior atlanto-axial fusion via screw rod constructs (SRC) or transarticular screws (TAS) that reported a patient with an injury to an arterial vessel directly attributable to the surgical procedure.

RESULTS

Sixty cases of vascular injury were reported in 2078 (2.9%) patients over 27 publications. The average age for this patient population was 55.7+/-17.9. Vascular injury following posterior C1/2 instrumentation resulted in ipsilateral stroke in 10.0% (n=6/60) and non-persistent neurologic deficit in 6.7% (n=4/60) of cases with the deficit being permanent (not including death) in 1.7% (n=1/60) of cases. Four patients (6.7%) died. Arteriovenous fistula or pseudoaneurysm occurred in 8.3% (n=5/60) and 3.3% (n=2/60) of cases, respectively. Eight patients (13.3%) underwent endovascular repair of the injury with no permanent deficit.

CONCLUSION

Neurological morbidity after iatrogenic vascular injury during posterior C1/2 fixation is higher than previously reported in literature. Some patients may benefit from endovascular treatment. Surgeons should be aware of normal and anomalous vertebral artery anatomy to avoid this potentially catastrophic complication.

Patient Experiences of Life Years After Severe Civilian Lower Extremity Trauma With Vascular Injury

OBJECTIVE

Severe lower limb trauma with arterial injury is often devastating for the individual. Many studies describe how to manage these injuries when they occur. Short-term functional outcome is quite well described, but the patients are often young, and their suffering is physical, mental, and social from a lifelong perspective. The aim of this study was to report patient experiences of their lives several years after their accidents, and to explore mechanisms of how to improve management.

METHOD

The Swedvasc registry was searched for participants from 1987 to 2011, living in the region of Uppsala, Sweden. Some amputated participants were added from the Walking Rehabilitation Center. There were five reconstructed patients with an intact limb, and three with amputations. In depth interviews were conducted and systematically analyzed, using A Giorgi's descriptive phenomenological method.

RESULTS

Eight patients participated, five with reconstructed and three with amputated limbs. Life affecting functional impairments were described by all patients. The patients undergoing amputation had received more structured follow up and support through the Walking Rehabilitation Center. The satisfaction with the cosmetic result was poorer than expected. All patients had developed strategies of how to cope with their impairments and stated they now lived "normal lives."

CONCLUSIONS

Despite substantial physical, psychological, and cosmetic impairments years after severe lower limb trauma, the participants described life as "normal" and mainly satisfactory. Transition to the new situation could have been facilitated by more frequent and continuous follow up after discharge from hospital, in particular among the non-amputated patients who tend to be lost to follow up. Findings also indicate that family members have to be acknowledged, strengthened, and supported.

Cytoprotective pathways in the vascular endothelium. Do they represent a viable therapeutic target?

The vascular endothelium is a critical interface, which separates the organs from the blood and its contents. The endothelium has a wide variety of functions and maintenance of endothelial homeostasis is a multi-dimensional active process, disruption of which has potentially deleterious consequences if not reversed. Vascular injury predisposes to endothelial apoptosis, dysfunction and development of atherosclerosis. Endothelial dysfunction is an end-point, a central feature of which is increased ROS generation, a reduction in endothelial nitric oxide synthase and increased nitric oxide consumption. A dysfunctional endothelium is a common feature of diseases including rheumatoid arthritis, systemic lupus erythematosus, diabetes mellitus and chronic renal impairment. The endothelium is endowed with a variety of constitutive and inducible mechanisms that act to minimise injury and facilitate repair. Endothelial cytoprotection can be enhanced by exogenous factors such as vascular endothelial growth factor, prostacyclin and laminar shear stress. Target genes include endothelial nitric oxide synthase, heme oxygenase-1, A20 and anti-apoptotic members of the B cell lymphoma protein-2 family. In light of the importance of endothelial function, and the link between its disruption and the risk of atherothrombosis, interest has focused on therapeutic conditioning and reversal of endothelial dysfunction. A detailed understanding of cytoprotective signalling pathways, their regulation and target genes is now required to identify novel therapeutic targets. The ultimate aim is to add vasculoprotection to current therapeutic strategies for systemic inflammatory diseases, in an attempt to reduce vascular injury and prevent or retard atherogenesis.

Evaluation of percutaneous microwave coagulation therapy for hepatic artery injury

Objectives

To evaluate the in vivo efficacy of 915 MHz percutaneous coagulation in the treatment of hepatic artery injury.

Methods

After inducing hepatic artery injury, 8 dogs in each group underwent 915 MHz microwave percutaneous coagulation therapy and 8 dogs were injected with batroxobin and α-cyanoacrylate.

Results

The hemostatic effects of 915 MHz microwave were better than drug injection, and the amount of bleeding was significantly lower (p < 0.05). Pathological examination showed that vessel wall necrosis were greater.

Conclusion

Contrast ultrasound guided 915 MHz microwave percutaneous coagulation treatment has potent hemostatic effects in the repair of in vivo hepatic artery injury.

Silent killer: A scalpel in the aortic wall after spinal surgery

Iatrogenic vascular injury during lumbar spinal surgery is rare, but may lead to serious complications in unrecognized cases. Especially, injuries to aorta or its major branches may result in death unless diagnosed and treated immediately. We present a rare case of aortic injury with a scalpel in a 56-year-old male patient undergoing lumbar disk surgery. The vascular injury was successfully treated with open surgery. The post-operative period was uneventful and the patient was discharged in a healthy condition on the 8th day. This case once again reminds us that surgery is always open to complications and that early diagnosis and appropriate interventions are of paramount importance to overcome these complications.

Nerve injuries of the upper extremity associated with vascular trauma-surgical treatment and outcome

Peripheral nerve injuries are often associated with injuries of adjacent tissue. As a result of anatomic proximity between nerves and vascular structures, there is a high chance of combined injuries of these structures (23 %). The aim of our study is to describe and analyze associated nerve and vascular injuries of the upper extremity in patients treated at the Clinic of Neurosurgery in Belgrade over a 10-year period. This study included 83 patients that received surgical treatment at the Clinic of Neurosurgery in Belgrade after having been diagnosed with upper extremity nerve injury. The study included all patients that satisfied these criteria over a period of 10 years. The patients with associated vascular injuries, 36 of them, were considered our study group, while 47 patients without associated vascular injuries were considered our control group. Finally, we compared treatment outcome between these groups. The final outcome evaluation was performed 2 years after surgical treatment. In our study group, 84.8 % surgical nerve repair was successful (fair, good, and excellent outcome), while in the control group (patients without vascular injury), surgical nerve repair was successful in 87.9 %. The overall satisfactory neurological outcome (M3-M5) was present in 86.6 % of nerve repairs. Our study shows that there is no significant difference between the treatment outcome in patients with associated nerve and vascular injuries and patients with isolated nerve injuries if they are diagnosed in time and treated appropriately. Successful treatment can only be accomplished through a multidisciplinary approach undertaken by a highly qualified medical team.

Fracture of the acetabulum with femoral artery injury presenting late: A case report

This study reports a rare case of both column acetabulum fracture with femoral artery injury that presented late and was managed with arterial reconstruction and fracture fixation.

A thirty-one year old man sustained both column acetabular fracture on the left in a motor vehicle accident. On admission there was no obvious neuro-vascular deficit. During surgery for the fracture after 7 days of the injury the femoral artery was found to be severely crushed with no blood flow. The anterior column of the acetabulum was stabilised followed by resection and reconstruction of the femoral artery. The post-operative period was uneventful and he was discharged normally. At 6 months from injury the fractures had united well with excellent limb circulation and good lower limb function.

Femoral artery injury with acetabular fracture is rare and late presentations are unreported hitherto. The results of fracture stabilisation and vessel reconstruction seem to be excellent. Literature of similar injuries is reviewed.

Changes in cross-sectional area of pulmonary vessels on chest computed tomography after chemotherapy in patients with advanced non-squamous non-small-cell lung cancer

PURPOSE

Chemotherapy is associated with a risk of vascular damage. Novel anti-angiogenic agents, which can directly affect tumor angiogenesis, are increasingly being used. However, the effects of these agents on normal vasculature are not well understood. Here, we evaluated the effects of chemotherapy in general, and the anti-angiogenic agent bevacizumab, more specifically, on the pulmonary vasculature in patients with advanced non-squamous non-small-cell lung cancer (NSCLC). For this, we used the cross-sectional area of pulmonary vessels (CSA), which is an easily measurable indicator of small pulmonary vasculature on non-contrast chest computed tomography (CT).

METHODS

We retrospectively reviewed CT scans of the lungs of 75 chemo-naïve patients with advanced non-squamous NSCLC, for measurement of CSA, before and after first-line platinum-based chemotherapy, using a semi-automatic image-processing program. Measured vessels were classified in two groups: small vessels with CSA <5 mm(2) and large vessels with CSA between 5 and 10 mm(2). The CSAs for each group of vessels were calculated and summed separately, and expressed as a percentage of the total lung area (%CSA<5 and %CSA5-10).

RESULTS

Chemotherapy was associated with a selective decrease in small-diameter vessels, with a significant decrease in %CSA<5, but not %CSA5-10. When comparing chemotherapy with bevacizumab (n = 38) and without bevacizumab (n = 37), there was no significant difference in the reduction of %CSA<5.

CONCLUSIONS

Platinum-based chemotherapy might induce small pulmonary vascular damage. Use of bevacizumab does not enhance the reduction in area of pulmonary vessels.

A hybrid approach to mid-shaft clavicle fixation

BACKGROUND

The purpose of this study was to demonstrate the strength characteristics of a hybrid uni-cortical construct for clavicle fixation. The technique reported aims to combine benefits of uni-cortical fixation with stability comparable to traditional bi-cortical fixation. The approach utilises long, oblique uni-cortical screws at the distal ends of the plate acting as surrogate bi-cortical screws. Locked uni-cortical screws positioned centrally provide bending and torsion strength to the construct. This alternative hybrid uni-cortical technique does not require far cortex screw or drill penetration required in bi-cortical fixation techniques, thus avoiding potentially catastrophic vascular and or neurologic injury. The purpose of this study was to compare the mechanical behaviour of the hybrid uni-cortical construct to standard bi-cortical fixations under both torsion and bending loads.

METHOD

Thirty osteotomized human cadaveric clavicles were randomly allocated to three surgical fixation techniques: bi-cortical locked screw fixation, bi-cortical non-locked screw fixation and hybrid uni-cortical screw fixation. Each clavicle construct was tested non-destructively under torsional loading, and then under cantilever bending to failure. Construct bending and torsional stiffness, as well as ultimate failure strength, were measured.

RESULTS

There were no significant differences between uni-cortical or bi-cortical fixation constructs in either bending stiffness or ultimate bending moment (p>0.05); however, there was a trend towards greater bending stiffness in the hybrid construct. The uni-cortical hybrid fixation technique displayed a significantly lower mean torsional stiffness value when compared with the bi-cortical locked screw fixation (mean difference: 134.4 Nmm/degrees, 95% confidence interval [32.3, 236.4], p=0.007).

CONCLUSION

A hybrid uni-cortical approach to clavicle plate fixation that may improve screw purchase and reduce risk of intra-operative vascular damage demonstrates comparable bending strength to current bi-cortical approaches.

Acute ischemia and pink pulseless hand in 68 of 404 gartland type III supracondylar humeral fractures in children: Urgent management and therapeutic consensus

No consensus exists regarding pulseless otherwise well-perfused hand in pediatric Gartland type III fractures. The purpose of this retrospective study was to describe our strategy and to determine the guidelines of therapeutic consensus.

PATIENTS AND METHODS

404 children were treated for a type III supracondylar humeral fracture. Extension fractures-induced acute vascular injuries were noticed in 68 patients and nerve injuries were associated in 32 of them. The radial pulse was absent in all patients with two clinical situations at the initial presentation: well-perfused hand with 'pink and warm' hand in 63 patients and ischemia with 'white and cold' hand in five. Urgent closed reduction of the fracture and stabilization were performed in 63 patients with pink pulseless hand, and immediate surgical exploration in the five patients with ischemia.

RESULTS

63 patients with vascular injury had posterolateral displacement and 5 had posteromedial displacement. Sixty-three of 68 patients had posterolateral displacement of whom 28 had concomitant median nerve injury and 4 had a deficit to both median and ulnar nerves. The palpable radial pulse was immediately restored in 42 patients and between few hours to eleven days later in eighteen. Three patients with ischemia after unsuccessful reduction required immediate surgical exploration revealing incarceration of the brachial artery at the fracture site. Release and decompression of the brachial artery restored a normal limb perfusion. The five patients with primary ischemia underwent immediate open exploration and vascular repair. One of them had a compartment syndrome and required anterior fasciotomy. The restoration of blood flow with palpable radial pulse was observed in all patients. Full spontaneous nerve recovery was observed in all patients. At an average follow-up of 8.4 years, all patients had normal circulatory status, including a palpable radial pulse.

DISCUSSION

This study highlighted the reliability of non invasive strategy with good outcomes. We recommend urgent closed reduction of fracture. Close observation and monitoring is mandatory if pulseless hand remains warm and well-perfused. If the patients develop blood circulation disturbances or compartment syndrome following closed reduction, immediate vascular exploration is recommend.

Simultaneous pancreas-kidney transplantation in patients with type 1 diabetes reverses elevated MBL levels in association with MBL2 genotype and VEGF expression

AIMS/HYPOTHESIS

High levels of circulating mannan-binding lectin (MBL) are associated with the development of diabetic nephropathy and hyperglycaemia-induced vasculopathy. Here, we aimed to assess the effect of glycaemic control on circulating levels of MBL and the relationship of these levels with vascular damage.

METHODS

We assessed MBL levels and corresponding MBL2 genotype, together with vascular endothelial growth factor (VEGF) levels as a marker of vascular damage, in type 1 diabetes patients with diabetic nephropathy before and after simultaneous pancreas-kidney (SPK) transplantation. We included diabetic nephropathy patients (n = 21), SPK patients (n = 37), healthy controls (n = 19), type 1 diabetes patients (n = 15) and diabetic nephropathy patients receiving only a kidney transplant (n = 15). Fourteen diabetic nephropathy patients were followed up for 12 months after SPK.

RESULTS

We found elevated circulating MBL levels in diabetic nephropathy patients, and a trend towards elevated circulating MBL levels in type 1 diabetes patients, compared with healthy control individuals. MBL levels in SPK patients completely normalised and our data indicate that this predominantly occurs in patients with a polymorphism in the MBL2 gene. By contrast, MBL levels in kidney transplant only patients remained elevated, suggesting that glycaemic control but not reversal of renal failure is associated with decreased MBL levels. In line, levels of glucose and HbA1c, but not creatinine levels and estimated GFR, were correlated with MBL levels. VEGF levels were associated with levels of MBL and HbA1c in an MBL-polymorphism-dependent manner.

CONCLUSIONS/INTERPRETATION

Taken together, circulating MBL levels are associated with diabetic nephropathy and are dependent on glycaemic control, possibly in an MBL2-genotype-dependent manner.

The ubiquitin-activating enzyme E1 as a novel therapeutic target for the treatment of restenosis

AIMS

The ubiquitin-activating enzyme E1 (UBA1, E1), the apex of the ubiquitin proteasome pathway, plays a critical role in protein degradation and in pathological processes. Whether UBA1 participates the development of vascular restenosis remains unknown. This study aims to determine the role of UBA1 in the development of balloon injury induced neointimal formation.

METHODS AND RESULTS

Immunostaining and western blots were used to examine the expression of the ubiquitinated protein in the injured carotid after angioplasty. Higher levels of ubiquitinated protein were observed in the neointima. Local delivery of potent chemical UBA1 inhibitor PYR-41 (100 μM) and UBA1 shRNA lentivirus both resulted in a substantial decrease in intimal hyperplasia at 2 weeks and 4 weeks after balloon injury. UBA1 inhibition also reduced Ki-67 positive cell percentage and inflammatory response in the carotid artery wall. We further determined that in vitro UBA1 inhibition was able to ameliorate TNF-α-induced nuclear factor-kappa B (NF-κB) activation by reducing IκB degradation in vascular smooth muscle cells (VSMCs). UBA1 inhibition also led to the accumulation of short-lived proteins such as p53, p21 and c-jun, which may account for the UBA1 inhibition-induced cell cycle delay. Thus, VSMCs proliferation was blocked.

CONCLUSIONS

UBA1 inhibition effectively suppresses neointimal thickening through its anti-proliferative and anti-inflammatory effects. Our results provide further evidence that the ubiquitin-proteasome system is a potential new target for the prevention of vascular restenosis.

Transcription factor KLF6 upregulates expression of metalloprotease MMP14 and subsequent release of soluble endoglin during vascular injury

After endothelial injury, the transcription factor Krüppel-like factor 6 (KLF6) translocates into the cell nucleus to regulate a variety of target genes involved in angiogenesis, vascular repair and remodeling, including components of the membrane transforming growth factor beta (TGF-β) receptor complex such as endoglin and activin receptor-like kinase 1. The membrane metalloproteinase 14 (MMP14 or MT1-MMP) targets endoglin to release soluble endoglin and is involved in vascular inflammation and endothelial tubulogenesis. However, little is known about the regulation of MMP14 expression during vascular wounding. In vitro denudation of monolayers of human endothelial cell monolayers leads to an increase in the KLF6 gene transcriptional rate, followed by an upregulation of MMP14 and release of soluble endoglin. Concomitant with this process, MMP14 co-localizes with endoglin in the sprouting endothelial cells surrounding the wound border. MMP14 expression at mRNA and protein levels is increased by ectopic KLF6 and downregulated by KLF6 suppression in cultured endothelial cells. Moreover, after wire-induced endothelial denudation, Klf6^+/− mice show lower levels of MMP14 in their vasculature compared with their wild-type siblings. Ectopic cellular expression of KLF6 results in an increased transcription rate of MMP14, and chromatin immunoprecipitation assays show that KLF6 interacts with MMP14 promoter in ECs, this interaction being enhanced during wound healing. Furthermore, KLF6 markedly increases the transcriptional activity of different reporter constructs of MMP14 gene promoter. These results suggest that KLF6 regulates MMP14 transcription and is a critical player of the gene expression network triggered during endothelial repair.