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Robbins JM, Crayton C, Koloditch I, Walk C, Gramajo L, Shugar S, Ekeh P, DuBose J, Wong Y, Layba C. In-Hospital Risk Factors for Reintervention and Amputation in Brachial Arterial Trauma. J Surg Res 2024; 300:318-324. [PMID: 38838429 DOI: 10.1016/j.jss.2024.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 05/04/2024] [Accepted: 05/09/2024] [Indexed: 06/07/2024]
Abstract
INTRODUCTION Brachial artery trauma is a rare but potentially devastating injury. There is little data regarding risk factors for reintervention and amputation prevention in this population, as well as anticoagulant (AC) and antiplatelet (AP) regimens and outcomes after discharge in trauma patients with vascular injuries requiring repair. This study aims to identify in-hospital risk factors for reintervention and amputation and stratify outcomes of follow-up by discharge AC or AP regimen. METHODS The AAST Prospective Observational Vascular Injury Trial database was queried for all patients who underwent traumatic brachial arterial repair from 2013 to 2022. Patients were evaluated by need for reintervention, amputation, and outcomes at follow-up by AC or AP regimen. RESULTS Three hundred and eleven patients required brachial repair, 28 (9%) required reoperation, and 8 (2.6%) required amputation. High injury severity score and an increased number of packed red blood cells and platelets showed a significant increase for reoperation and amputation. Damage control and shunt use were significant for the need to reoperate. Seventy-four percent (221/298) of patients were discharged with postoperative AC or AP regimens. There was no significant difference of short-term follow-up by type of AC or AP regimen. CONCLUSIONS Damage control and temporary shunt may lead to additional operations but not an increase in amputations. However, anticoagulation intraoperatively and postoperatively does not appear to play a significant role in reducing reintervention. It also suggests that there is no increase in short-term follow-up complications with or without AC or AP therapy.
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Affiliation(s)
| | | | | | - Casey Walk
- Wright State University Department of Surgery, Dayton, Ohio
| | - Limayre Gramajo
- Oklahoma State University College of Osteopathic Medicine, Tulsa, Oklahoma
| | | | - Peter Ekeh
- Wright State University Department of Surgery, Dayton, Ohio
| | - Joseph DuBose
- University of Texas Department of Surgery, Austin, Texas
| | - Yee Wong
- Wright State University Department of Surgery, Dayton, Ohio
| | - Cathline Layba
- Wright State University Department of Surgery, Dayton, Ohio
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Harting MT, Drucker NA, Chen W, Cotton BA, Wang SK, DuBose JJ, Cox CS. Principles and Practice in Pediatric Vascular Trauma: Part 2: Fundamental Vascular Principles, Pediatric Nuance, and Follow-up Strategies. J Pediatr Surg 2024:161655. [PMID: 39168787 DOI: 10.1016/j.jpedsurg.2024.07.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2024] [Accepted: 07/25/2024] [Indexed: 08/23/2024]
Abstract
As of 2020, penetrating injuries became the leading cause of death among children and adolescents ages 1-19 in the United States. For those patients who survive and receive advanced medical care, vascular injuries are a significant cause of morbidity and trigger notable trauma team angst. Moreover, penetrating injuries can lead to life-threatening hemorrhage and/or limb-threatening ischemia if not addressed promptly. Vascular injury management demands timely and unique expertise, particularly for pediatric patients. In part 1 of this review, we discussed the scope and extent of the epidemic of traumatic vascular injuries in pediatric patients, reviewed current evidence and outcomes, discussed various challenges and advantages of a myriad of existing team structures, and outlined potential outcome targets and solutions. However, in order to optimize care for pediatric vascular trauma, we must also understand the fundamental best practice principles, surgical options and approaches, medical management, and recommendations for ongoing, outpatient follow-up. In part 2, we will address the best evidence, combined with expert consensus, regarding strategies for diagnosing, managing, and ongoing follow-up of vascular trauma, with particular focus on the nuances that define the unique approaches to pediatric patients. LEVEL OF EVIDENCE: n/a.
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Affiliation(s)
- Matthew T Harting
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center, Houston, TX, USA; Red Duke Trauma Institute at Memorial Hermann - Texas Medical Center, Houston, TX, USA; Children's Memorial Hermann Hospital, Houston, TX, USA.
| | - Natalie A Drucker
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center, Houston, TX, USA; Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Wendy Chen
- Children's Memorial Hermann Hospital, Houston, TX, USA; Department of Surgery, Division of Pediatric Plastic Surgery, McGovern Medical School at The University of Texas Health Science Center, Houston, TX, USA
| | - Bryan A Cotton
- Red Duke Trauma Institute at Memorial Hermann - Texas Medical Center, Houston, TX, USA; Department of Surgery, Division of Acute Care Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - S Keisin Wang
- Department of Cardiothoracic and Vascular Surgery, Division of Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center, Houston, TX, USA; Heart and Vascular Institute, Memorial Hermann - Texas Medical Center, Houston, TX, USA
| | - Joseph J DuBose
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Charles S Cox
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center, Houston, TX, USA; Red Duke Trauma Institute at Memorial Hermann - Texas Medical Center, Houston, TX, USA; Children's Memorial Hermann Hospital, Houston, TX, USA.
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Hatori Y, Tajika T, Kuboi T, Negishi R, Chikuda H. Heparin-Induced Thrombocytopenia After Revascularization of Gustilo-Anderson Type IIIC Open Lower Leg Fracture: A Case Report of Subsequent Ischemic Limb Salvage Failure. AMERICAN JOURNAL OF CASE REPORTS 2024; 25:e944121. [PMID: 38944681 PMCID: PMC11332957 DOI: 10.12659/ajcr.944121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 05/15/2024] [Accepted: 05/03/2024] [Indexed: 07/01/2024]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is a disease in which the immune response elicited by heparin results in a state of hypercoagulability and platelet activation, leading to thrombocytopenia and thromboembolism. Gustilo-Anderson type IIIC open fractures of the extremities are defined as open fractures presenting with arterial injuries that require repair and result in treatment challenges and complications. The diagnosis of HIT can be difficult in patients with severe trauma with consumptive thrombocytopenia associated with heavy bleeding and the use of heparin after vascular anastomosis. CASE REPORT A 48-year-old man was injured in a car accident, pinching his right lower leg and sustaining a Gustilo-Anderson type IIIc open fracture, for which he underwent emergency revascularization surgery. Heparin was administered continuously immediately after the surgery. On postoperative day 9, ischemic changes were observed in the right foot, and we performed suture re-anastomosis; however, the blood circulation in the right lower leg did not resume, and right lower leg amputation was performed due to ischemic necrosis with the onset of HIT. Postoperatively, the patient was switched to edoxaban after the recovery of his platelet count. Thereafter, the patient experienced no new thrombus occlusion or wound trouble, and was able to walk on a prosthetic leg and return to daily life. CONCLUSIONS It is important to consider the possibility of HIT as soon as thrombocytopenia appears in patients with Gustilo-Anderson type IIIC open fracture who are receiving heparin after vascular anastomosis, as a delayed diagnosis of HIT can make it difficult to save the limb.
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Affiliation(s)
- Yuhei Hatori
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Tsuyoshi Tajika
- Applied Rehabilitation Sciences, Graduate School of Health Sciences, Gunma University, Maebashi, Gunma, Japan
| | - Takuro Kuboi
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Ryousuke Negishi
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Hirotaka Chikuda
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
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Stonko DP, Betzold RD, Azar FK, Edwards J, Abdou H, Elansary NN, Gerling KA, White J, Feliciano DV, DuBose JJ, Morrison JJ. Postoperative antiplatelet and/or anticoagulation use does not impact complication or reintervention rates after vein repair of arterial injury: A PROOVIT study. Vascular 2023; 31:777-783. [PMID: 35430941 DOI: 10.1177/17085381221082371] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
INTRODUCTION The use of antiplatelet (AP) and anticoagulation (AC) therapy after autogenous vein repair of traumatic arterial injury is controversial. The hypothesis in this study was that there is no difference in early postoperative outcomes regardless of whether AC, AP, both, or neither are used. METHODS The American Association for the Surgery of Trauma (AAST) PROspective Observational Vascular Injury Treatment (PROOVIT) registry was queried from November, 2013, to January, 2019, for arterial injuries repaired with a vein graft. Demographics and injury characteristics were compared. Need for in-hospital reoperation was the primary outcome in this four-arm study, assessed with two ordinal logistic regression models (1. no therapy vs. AC only vs. AC and AP; 2. no therapy vs. AP only vs. AC and AP). RESULTS 373 patients (52 no therapy, 88 AP only, 77 AC only, 156 both) from 19 centers with recorded Injury Severity Scores (ISS) were identified. Patients who received no therapy were younger than those who received AP (27.0 vs. 34.2, p = 0.02), had higher transfusion requirement (p < 0.01 between all groups) and a different distribution of anatomic injury (p < 0.01). After controlling for age, sex, ISS, platelet count, hemoglobin, pH, lactate, INR, transfusion requirement and anatomic location, there was no association with postoperative medical therapy and in-hospital operative reintervention, or any secondary outcome, including thrombosis (p = 0.67, p = 0.22). CONCLUSIONS Neither AC nor AP alone, nor in combination, impact complication rate after arterial repair with autologous vein. These patients can be safely treated with or without antithrombotics, recognizing that this study did not demonstrate a beneficial effect.
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Affiliation(s)
- David P Stonko
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Richard D Betzold
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Faris K Azar
- St Mary's Medical Center, West Palm Beach, Florida Atlantic University, Boca Raton, FL USA
| | - Joseph Edwards
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Hossam Abdou
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Noha N Elansary
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | | | - Joseph White
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - David V Feliciano
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Joseph J DuBose
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Jonathan J Morrison
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
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Helfen T. [23/m-Psychosis with sequelae : Preparation for the medical specialist examination: part 46]. Unfallchirurg 2020; 124:123-128. [PMID: 33216201 DOI: 10.1007/s00113-020-00918-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Tobias Helfen
- Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, LMU Klinikum, Nußbaumstr. 20, 80336, München, Deutschland.
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Selecting the right limb, at the right time, for the right reason: response to "A meta-analysis on anticoagulation after vascular trauma". Eur J Trauma Emerg Surg 2020; 47:273-274. [PMID: 32719896 DOI: 10.1007/s00068-020-01438-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 07/12/2020] [Indexed: 10/23/2022]
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