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Almadwahi NY, Alkadri AM, Fadhel A, Alshujaa M, Ahmed F, Badheeb M. Iatrogenic Vascular Injuries in Resource-Limited Setting: A 4-Year Experience Monocentric Retrospective Study. Open Access Emerg Med 2024; 16:57-64. [PMID: 38650668 PMCID: PMC11034556 DOI: 10.2147/oaem.s450213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 04/17/2024] [Indexed: 04/25/2024] Open
Abstract
Background Iatrogenic vascular injuries (IVIs) due to diagnostic and therapeutic interventions are known but rare or probably under-reported. We present our four-year findings on patients with IVIs after catheterization or surgery who underwent vascular surgical repairs in a resource-limited setting. Methods A retrospective case series study between Jun 2018 and Sep 2022 of 35 patients diagnosed with IVIs and treated surgically at our hospital was included. The data on IVIs including patient characteristics, causes and type of injury, treatment, and outcomes were collected and analyzed. Results The mean age was 37.12± 17.0 years, and most patients (65.7%) were male. Of the 35 IVIs, 21 were caused by percutaneous procedures, while 14 occurred intraoperatively and affected various arteries and veins. The main injured vessels were the femoral artery (20%) and direct blood vessel puncture made by non-qualified specialists (42.9%) during dialysis cannulation was the main cause. The intraoperative IVI affected the inferior vena cava in three patients, the aorta in two patients, the external iliac artery in four, the tibial and popliteal arteries in four, and the internal carotid artery in one. The following types of repairs were recorded: direct suture of the vessel with or without endarterectomy (71.4%), synthetic patch placement (25.7%), ligation (8.6%), bypass or interposition graft (14.3%), and thromboembolectomy (5.7%). Vascular repair was successful in 32 (91.4%) patients while three patients (8.6%) were expired. Complications occurred in 7 (20%) patients, of which superficial wound infections were the common complication (11.6%) and were treated with proper antibiotic therapy. Conclusion Prompt identification of IVIs, as well as proper triage for future treatment, can enhance patient outcomes. Our data showed that non-qualified specialists seem to be responsible for the majority of IVIs. For that, we emphasize the importance of performing vascular procedures by a qualified specialist with adequate training.
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Affiliation(s)
| | | | - Ali Fadhel
- Department of Cardio-Pediatric Surgery, School of Medicine, Sana’a University, Sana’a, Yemen
| | - Mohamed Alshujaa
- Department of Vascular Surgery, School of Medicine, Sana’a University, Sana’a, Yemen
| | - Faisal Ahmed
- Department of Urology, School of Medicine, Ibb University, Ibb, Yemen
| | - Mohamed Badheeb
- Department of Internal Medicine, Yale New-Haven Health/Bridgeport Hospital, Bridgeport, CT, USA
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Ng JPH, Wu C, Ooi DGS, Leong CR, Chan DYS. Review of peripheral artery trauma in a district hospital in northern Singapore. Singapore Med J 2024:00077293-990000000-00076. [PMID: 38189453 DOI: 10.4103/singaporemedj.smj-2022-081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 09/27/2022] [Indexed: 01/09/2024]
Affiliation(s)
- Julia Poh Hwee Ng
- Department of General Surgery, Vascular Surgery, Khoo Teck Puat Hospital, Singapore
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Derbel B, Mazzaccaro D, Krarti N, Miri R, Khadhar Y, Ben Mrad M, Righini P, Nano G, Denguir R. Penetrating Vascular Injuries of the Lower Limbs after Stab Wounds: Predictive Factors of Limb Loss and Mortality. J Clin Med 2023; 12:jcm12103476. [PMID: 37240581 DOI: 10.3390/jcm12103476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/11/2023] [Accepted: 05/13/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Penetrating vascular injuries (PVIs) of the lower limbs due to stab wounds are associated with high mortality and limb loss rates. We analyzed the outcomes of a series of patients who underwent surgical treatment of these lesions, assessing the presence of any factor associated with limb loss and mortality; (2) Methods: Data of patients admitted from 01/2008 to 12/2018 were retrospectively analyzed. Primary outcomes were the limb loss and the mortality rate at 30 days postoperatively. Univariate and multivariate analyses were performed as appropriate. p values < 0.05 were considered significant; (3) Results: Data of 67 male patients were analyzed. Two died (3%) and three (4.5%) had a lower limb amputation after failed revascularization. In the univariate analysis, the clinical presentation significantly affected the risk of postoperative mortality and limb loss. The location of the lesion at the superficial femoral artery (OR 4.32, p = 0.001) or at the popliteal artery (OR 4.89, p = 0.0015) also increased the risk. In the multivariate analysis, the need for a vein graft bypass was the only significant predictor of limb loss and mortality (OR 4.58, p < 0.0001); (4) Conclusions: PVIs of lower limbs due to stab wounds were lethal in 3% of cases and lead to a secondary major amputation in 4.5% more cases. The need for a vein bypass grafting was the strongest predictor of postoperative limb loss and mortality.
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Affiliation(s)
- Bilel Derbel
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis 1002, Tunisia
- Cardiovascular Surgery Department, La Rabta Hospital, Tunis 1007, Tunisia
| | - Daniela Mazzaccaro
- Operative Unit of Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, 20097 Milan, Italy
| | - Nidhal Krarti
- Cardiovascular Surgery Department, La Rabta Hospital, Tunis 1007, Tunisia
| | - Rim Miri
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis 1002, Tunisia
- Cardiovascular Surgery Department, La Rabta Hospital, Tunis 1007, Tunisia
| | - Yassine Khadhar
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis 1002, Tunisia
- Cardiovascular Surgery Department, La Rabta Hospital, Tunis 1007, Tunisia
| | - Melek Ben Mrad
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis 1002, Tunisia
- Cardiovascular Surgery Department, La Rabta Hospital, Tunis 1007, Tunisia
| | - Paolo Righini
- Operative Unit of Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, 20097 Milan, Italy
| | - Giovanni Nano
- Cardiovascular Surgery Department, La Rabta Hospital, Tunis 1007, Tunisia
- Department of Biomedical Sciences for Health, University of Milan, 20161 Milan, Italy
| | - Raouf Denguir
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis 1002, Tunisia
- Cardiovascular Surgery Department, La Rabta Hospital, Tunis 1007, Tunisia
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Mahajan RK, Srinivasan K, Jain A, Bhamre A, Narayan U, Sharma M. Management of Complex Upper Extremity Trauma with Associated Vascular Injury. Indian J Plast Surg 2022; 55:224-233. [DOI: 10.1055/s-0042-1744453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Abstract
Introduction Combined soft tissue and vascular injuries of the upper extremity pose several challenges at once to the plastic surgeon. Many decisions have to be taken urgently that will influence the salvage or amputation of the affected extremity. The aim of this article was to provide an evidence-based outline for the management of such injuries. Learning objectives of this article are as follows: (1) approach to a patient with upper extremity composite tissue and vascular injury presenting to the emergency, (2) decision-making as to when to salvage and when to go for amputation of the traumatized upper extremity, (3) role of imaging in emergency situation, (4) role of fasciotomy, (5) intraoperative sequencing of steps, and (6) options for vascular reconstruction and the flaps used for coverage. After reading this article, the reader should have a clear understanding of the management of vascular injury in a patient with composite defects of upper extremity.
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Affiliation(s)
- Ravi K. Mahajan
- Department of Plastic and Reconstructive Surgery, Amandeep Hospital, Amritsar, Punjab, India
| | - Krishnan Srinivasan
- Department of Plastic and Reconstructive Surgery, Amandeep Hospital, Amritsar, Punjab, India
| | - Adish Jain
- Department of Plastic and Reconstructive Surgery, Amandeep Hospital, Amritsar, Punjab, India
| | - Abhishek Bhamre
- Department of Plastic and Reconstructive Surgery, Amandeep Hospital, Amritsar, Punjab, India
| | - Udit Narayan
- Department of Plastic and Reconstructive Surgery, Amandeep Hospital, Amritsar, Punjab, India
| | - Manish Sharma
- Department of Plastic and Reconstructive Surgery, Amandeep Hospital, Amritsar, Punjab, India
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Bhalla D, Kumar A, Gamanagatti S, Sagar S, Kumar S, Gupta A. Imaging in extremity vascular trauma: can MDCT angiography predict the nature of injury? Emerg Radiol 2022; 29:683-690. [PMID: 35467224 DOI: 10.1007/s10140-022-02050-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 04/14/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE This study aims to evaluate the utility of computed tomography angiography (CTA) signs of vascular injury in the differentiation of vessel transection from pure thrombosis with intact vessel wall. METHODS Retrospective analysis was done on 146 consecutive patients who had undergone CTA and surgical exploration from January 2015 to September 2019. Twelve imaging parameters were assessed. Chi-square was used to test the difference between groups. In addition, a scoring system was devised where one point each was added for the presence of 5 signs and absence of 3 signs. ROC analysis was done for the variables which had shown significant difference between groups and for the composite score. RESULTS On surgical exploration, 87 patients had transection of vessel, while 59 had thrombosis. Significant difference was found among the two groups in non-opacification, pseudoaneurysm, extravasation (p = 0.04 each), thrombosed cord (p < 0.001), collaterals (p = 0.001) and hematoma (p = 0.002), while other signs did not show significant difference. The AUC value for each of these variables was < 0.650, while for the score, AUC was .843(.773-.913). A cut-off value of ≥ 1.5 gave 83.1% sensitivity and 70% specificity for diagnosing transection. CONCLUSION CTA is a useful tool to classify the nature of vascular injury. It is advisable to use a composite score for maximum diagnostic value.
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Affiliation(s)
- Deeksha Bhalla
- Department of Radiodiagnosis, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Atin Kumar
- Department of Radiodiagnosis, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India.
| | - Shivanand Gamanagatti
- Department of Radiodiagnosis, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Sushma Sagar
- Department of Surgical Disciplines, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Subodh Kumar
- Department of Surgical Disciplines, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Amit Gupta
- Department of Surgical Disciplines, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
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le Roux A, Du Plessis AM, Pitcher R. Yield of CT angiography in penetrating lower extremity trauma. Emerg Radiol 2021; 28:743-749. [PMID: 33619684 DOI: 10.1007/s10140-021-01902-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 01/18/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE CT angiography (CTA) has become a valuable tool in the assessment of suspected arterial injury in patients with penetrating lower extremity trauma. However, expensive imaging such as CTA should be judiciously utilized to ensure value-based care. We therefore assessed the yield of CTA in this setting at a level-1 trauma unit and correlated it with the clinical history provided. METHODS A retrospective descriptive study from 1 July 2013 to 31 June 2018 at a 1386-bed, tertiary-level, public-sector teaching hospital in Cape Town, South Africa.. All patients undergoing CTA for suspected arterial injury following penetrating lower extremity trauma were included. The imaging yield of clinically significant arterial injury and the predictive value of specific clinical signs were determined. RESULTS A total of 983 patients (median age 27 years, 91% male) were included; 90% (886/983) had gunshots, 9% (89/983) stabs, and 1% (8/983) other injuries. Despite an average 13% year-on-year increase in CTA performed, there was no change in the proportion demonstrating arterial injury. Thirty-four percent (23/68) of patients with strong (hard) signs of arterial injury (active pulsatile bleeding, rapidly expanding hematoma, absent pulse, palpable thrill, or audible bruit), 11% (49/459) with moderate (soft) signs (history of an arterial bleed, excessive non-pulsatile bleeding, large non-expanding hematoma, major neurological deficit, diminished but appreciable pulse, and arterial proximity), and 5% (24/456) with no indication for imaging had clinically significant arterial injuries. Significant positive correlations were rapidly expanding hematoma (p = 0.009), an absent pulse (p < 0.001), and a diminished pulse (p < 0.001). Significant negative correlations were proximity to a major artery (p = 0.005) and no clinical indication provided (p < 0.001). CONCLUSION There is poor correlation between clinical details provided and the presence of arterial injury at our institution. In this context, CTA serves a pivotal role in the definitive identification of arterial injury.
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Affiliation(s)
- Alwyn le Roux
- Division of Radiodiagnosis, Department of Medical Imaging and Clinical Oncology, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000, South Africa.
| | - Anne-Marie Du Plessis
- Division of Radiodiagnosis, Department of Medical Imaging and Clinical Oncology, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000, South Africa
| | - Richard Pitcher
- Division of Radiodiagnosis, Department of Medical Imaging and Clinical Oncology, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000, South Africa
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Francois CJ, Skulborstad EP, Kalva SP, Majdalany BS, Collins JD, Eldrup-Jorgensen J, Ferencik M, Ganguli S, Kendi AT, Khaja MS, Obara P, Ptak T, Reis SP, Sutphin PD, Dill KE. ACR Appropriateness Criteria ® Nonatherosclerotic Peripheral Arterial Disease. J Am Coll Radiol 2020; 16:S174-S183. [PMID: 31054743 DOI: 10.1016/j.jacr.2019.02.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 02/08/2019] [Indexed: 11/17/2022]
Abstract
A broad range of nonatherosclerotic diseases affect the peripheral arteries. The appropriate initial diagnostic imaging studies vary, depending upon the clinical presentation and suspicion of disease. Accurate vascular imaging relies upon visualization of the vessel lumen, vessel wall, and surrounding soft-tissue structures, with some modalities also offering the ability to characterize blood flow direction and velocity. Furthermore, nonvascular findings are often paramount in supporting a suspected clinical syndrome or guiding surgical management. The scenarios discussed in this document include the initial evaluation of suspected popliteal entrapment syndrome, external iliac artery endofibrosis, lower-extremity inflammatory vasculitides, dissection or connective tissue disease, noninflammatory vascular disease, and vascular trauma. The American College of Radiology 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.
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Affiliation(s)
| | | | | | | | - Bill S Majdalany
- Panel Vice Chair, University of Michigan Health System, Ann Arbor, Michigan
| | | | | | - Maros Ferencik
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon; Society of Cardiovascular Computed Tomography
| | | | | | | | - Piotr Obara
- Loyola University Medical Center, Maywood, Illinois
| | - Thomas Ptak
- University of Maryland Medical Center, Baltimore, Maryland
| | | | | | - Karin E Dill
- Specialty Chair, UMass Memorial Medical Center, Worcester, Massachusetts
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Gupta AK, Burgos MI, Azar F, Rueda M, Hus N. Vascular Shunt for Small Vessel Trauma in a Polytrauma Patient. Cureus 2020; 12:e9150. [PMID: 32789087 PMCID: PMC7417326 DOI: 10.7759/cureus.9150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
A 15-year-old male patient presented with multiple gunshot injuries. The patient underwent emergency lifesaving exploratory laparotomy and subsequently needed repair of his left upper limb ulnar artery injury. A shunt helped restore blood flow to the hand in a setting of damage control surgery in an exsanguinating patient with an ulnar artery injury having a massive disruption. After resuscitation, the patient underwent definitive repair of the artery using a vein interposition graft.
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Affiliation(s)
- Anupam K Gupta
- Minimally Invasive Surgery, University of Miami Hospital, Miami, USA
| | - Monica I Burgos
- Internal Medicine, Universidad Autonoma de Guadalajara, Guadalajara, MEX
| | - Faris Azar
- Surgery, St. Mary's Medical Center, West Palm Beach, USA
| | - Mario Rueda
- Trauma and Acute Care Surgery, St. Mary's Hospital, Boca Raton, USA
| | - Nir Hus
- Surgery, Delray Medical Center, Delray Beach, USA.,Surgery, Florida Atlantic University, Boca Raton, USA
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Akhmedov MB, Abushov NS, Zakirdzhayev ED, Abdullayev AG, Zeynalova GM, Aliyev EN, Tagizade GT. [Efferent methods and hyperbaric oxygen therapy for great vessels injuries of extremities]. Khirurgiia (Mosk) 2019:13-18. [PMID: 30855585 DOI: 10.17116/hirurgia201902113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To evaluate an efficacy of efferent therapy of great vessels injuries of extremities and acute limb ischemia. MATERIAL AND METHODS There were 197 patients (main group -107, control group - 90 patients) with great vessels injuries of extremities and acute limb ischemia. The patients of the main group underwent plasmapheresis, ultraviolet irradiation of blood (UVIB) and hyperbaric oxygen (HBO) therapy. Efferent methods were used depending on the severity of acute ischemia, intoxication and infection (intoxication - plasmapheresis, ischemia - plasmapheresis + HBO, infections - UVIB, their combination - plasmapheresis + UVIB + HBO). RESULTS Limb amputation and necrectomy were required only in 2 (1.96%) and 3 (2.8%) patients of the main group, mortality - 0.94% (n=1). In the control group these values were 16 (17.8%), 10 (11.1%) and 7 (7.8%), respectively. CONCLUSION Efferent methods are effective in patients with traumatic vascular injuries and acute limb ischemia regarding improvement of clinical outcomes and 2-fold reduction of hospital-stay, less number of amputations and decreased mortality rate.
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Affiliation(s)
- M B Akhmedov
- Topchubashov Research Center for Surgery, Azerbaijan Republic, Baku, Azebaijan
| | - N S Abushov
- Topchubashov Research Center for Surgery, Azerbaijan Republic, Baku, Azebaijan
| | - E D Zakirdzhayev
- Topchubashov Research Center for Surgery, Azerbaijan Republic, Baku, Azebaijan
| | - A G Abdullayev
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - G M Zeynalova
- Topchubashov Research Center for Surgery, Azerbaijan Republic, Baku, Azebaijan
| | - E N Aliyev
- Topchubashov Research Center for Surgery, Azerbaijan Republic, Baku, Azebaijan
| | - G T Tagizade
- Topchubashov Research Center for Surgery, Azerbaijan Republic, Baku, Azebaijan
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