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Kim P, Noorbakhsh S, Weeks A, Roorbach M, Dantes G, Santos A, Freedberg ME, Ramos C, Smith R, Castater CA, Nguyen J, Benarroch-Gampel J, Rajani RR, Todd SR, Sciarretta JD. Lower Extremity Vascular Injury in the Pediatric Trauma Patient: Management and Outcomes at an Adult Level I Trauma Center. Ann Vasc Surg 2024; 100:208-214. [PMID: 37914070 PMCID: PMC10922229 DOI: 10.1016/j.avsg.2023.09.078] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/23/2023] [Accepted: 09/26/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Traumatic vascular injuries of the lower extremity in the pediatric population are uncommon but can result in significant morbidity. The objective of this study is to demonstrate our experience with these injuries by describing patterns of traumatic vascular injury, the initial management, and data regarding early outcomes. METHODS In total, 506 patients presented with lower extremity vascular injury between January 1, 2009 and January 1, 2021 to Grady Memorial Hospital, an urban, adult Level I trauma center in Atlanta, Georgia. Thirty-two of the 506 patients were aged less than 18 years and were evaluated for a total of 47 lower extremity vascular injuries. To fully elucidate the injury patterns and clinical course in this population, we examined patient demographics, mechanism of injury, type of vessel injured, surgical repair performed, and early outcomes and complications. RESULTS The median (interquartile range) age was 16 (2) years (range, 3-17 years), and the majority were male (n = 29, 90.6%). Of the vascular injuries identified, 28 were arterial and 19 were venous. Of these injuries, 14 patients had combined arterial-venous injuries. The majority of injuries were the result of a penetrating injury (n = 28, 87.5%), and of these, all but 2 were attributed to gunshot wounds. Twenty-seven vascular interventions were performed by nonpediatric surgeons: 11 by trauma surgeons, 13 by vascular surgeons, 2 by orthopedic surgeons, and 1 by an interventional radiologist. Two patients required amputation: 1 during the index admission and 1 delayed at 3 months. Overall survival was 96.9%. CONCLUSIONS Vascular injuries as the result of trauma at any age often require early intervention, and we believe that these injuries in the pediatric population can be safely managed in adult trauma centers with a multidisciplinary team composed of trauma, vascular, and orthopedic surgeons with the potential to decrease associated morbidity and mortality from these injuries.
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Affiliation(s)
- Phillip Kim
- Department of Surgery, Emory University School of Medicine, Emory University Hospital, Atlanta, GA; Grady Memorial Hospital, Marcus Trauma Center, Atlanta, GA
| | - Soroosh Noorbakhsh
- Department of Surgery, Emory University School of Medicine, Emory University Hospital, Atlanta, GA.
| | - Ahna Weeks
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, WA
| | - Madeline Roorbach
- Department of Surgery, Emory University School of Medicine, Emory University Hospital, Atlanta, GA; Grady Memorial Hospital, Marcus Trauma Center, Atlanta, GA
| | - Goeto Dantes
- Department of Surgery, Emory University School of Medicine, Emory University Hospital, Atlanta, GA; Grady Memorial Hospital, Marcus Trauma Center, Atlanta, GA
| | - Adora Santos
- Department of Surgery, Emory University School of Medicine, Emory University Hospital, Atlanta, GA; Grady Memorial Hospital, Marcus Trauma Center, Atlanta, GA
| | - Mari E Freedberg
- Department of Surgery, Emory University School of Medicine, Emory University Hospital, Atlanta, GA; Grady Memorial Hospital, Marcus Trauma Center, Atlanta, GA
| | - Christopher Ramos
- Department of Surgery, Emory University School of Medicine, Emory University Hospital, Atlanta, GA; Grady Memorial Hospital, Marcus Trauma Center, Atlanta, GA
| | - Randi Smith
- Department of Surgery, Emory University School of Medicine, Emory University Hospital, Atlanta, GA; Grady Memorial Hospital, Marcus Trauma Center, Atlanta, GA
| | - Christine A Castater
- Department of Surgery, Emory University School of Medicine, Emory University Hospital, Atlanta, GA; Grady Memorial Hospital, Marcus Trauma Center, Atlanta, GA
| | - Jonathan Nguyen
- Grady Memorial Hospital, Marcus Trauma Center, Atlanta, GA; Department of Surgery, Morehouse School of Medicine, Atlanta, GA
| | - Jaime Benarroch-Gampel
- Department of Surgery, Emory University School of Medicine, Emory University Hospital, Atlanta, GA; Grady Memorial Hospital, Marcus Trauma Center, Atlanta, GA
| | - Ravi R Rajani
- Department of Surgery, Emory University School of Medicine, Emory University Hospital, Atlanta, GA; Grady Memorial Hospital, Marcus Trauma Center, Atlanta, GA
| | - S Rob Todd
- Department of Surgery, Emory University School of Medicine, Emory University Hospital, Atlanta, GA; Grady Memorial Hospital, Marcus Trauma Center, Atlanta, GA
| | - Jason D Sciarretta
- Department of Surgery, Emory University School of Medicine, Emory University Hospital, Atlanta, GA; Grady Memorial Hospital, Marcus Trauma Center, Atlanta, GA
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Alexopoulou-Prounia L, Kakkos SK, Mystakidi V, Ntouvas I, Kraniotis P, Sintou E. Vascular handlebar syndrome with blunt injury of common femoral artery. VASA 2023; 52:86-96. [PMID: 36698255 DOI: 10.1024/0301-1526/a001054] [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: 01/27/2023]
Abstract
Vascular handlebar syndrome with blunt injury of the common femoral artery is a rare vascular trauma mechanism, with high possibility of being missed or delayed. We present two cases of vascular handlebar syndrome treated in our hospital and a systematic review of the literature using MEDLINE and SCOPUS databases. Literature review identified 20 similar cases. The median age of patients was 18 years, and in vast majority males in gender. In most cases, the common femoral artery injury was an intimal flap and lumen occlusion with intramural thrombosis followed by transection and intimal injury without occlusion or thrombosis. The median time between injury and diagnosis/treatment was half an hour. Clinical presentation ranged from asymptomatic to acute limb ischemia. The grade of acute ischemia was mostly Rutherford class I (n=14), while acute IIa (n=4), chronic ischemia (n=3), and no ischemia (n=1) were also noticed. The correct diagnosis was revealed by clinical examination only (n=1), or by the combination of clinical and imaging techniques including computed tomography angiography (n=7) and duplex ultrasonography (n=4) or both (n=10). Management of the handlebar trauma syndrome injuries was surgical in most cases. Outcome was favorable in all patients. Vascular handlebar syndrome is extremely rare and high suspicion is required for early diagnosis and definitive treatment, as the early management is effective and crucial for averting the devastating consequences. An individualized approach to the vascular trauma patient is to be applied with considerations taken to the age of the patient, the mechanism of the injury, the anatomy of the lesion, and symptomatology of the case.
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Affiliation(s)
| | - Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Vasiliki Mystakidi
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Ioannis Ntouvas
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Pantelis Kraniotis
- Department of Radiology, University of Patras Medical School, Patras, Greece
| | - Eleni Sintou
- Department of Anesthesiology, University of Patras Medical School, Patras, Greece
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3
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Feliciano DV. Where is the femoral vein? A vascular case report. Trauma Surg Acute Care Open 2022; 7:e000979. [PMID: 35891679 PMCID: PMC9260837 DOI: 10.1136/tsaco-2022-000979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- David V Feliciano
- Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
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4
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Stefanou N, Arnaoutoglou C, Papageorgiou F, Matsagkas M, Varitimidis SE, Dailiana ZH. Update in combined musculoskeletal and vascular injuries of the extremities. World J Orthop 2022; 13:411-426. [PMID: 35633747 PMCID: PMC9125001 DOI: 10.5312/wjo.v13.i5.411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 10/31/2021] [Accepted: 04/24/2022] [Indexed: 02/06/2023] Open
Abstract
Combined musculoskeletal and vascular injuries of the extremities are conditions in which a multidisciplinary approach is a sine qua non to ensure life initially and limb viability secondarily. Vascular injuries as part of musculoskeletal trauma are usually the result of the release of a high energy load in the wound site so that the prognosis is determined by the degree of soft-tissue damage, duration of limb ischemia, patient’s medical status and presence of associated injuries. The management of these injuries is challenging and requires a specific algorithm of action, because they are usually characterized by increased morbidity, amputation rate, infection, neurological and functional deficits, and they could be life threatening. Although vascular injuries are rare and occur either isolated or in the context of major combined musculoskeletal trauma, the high index of suspicion, imaging control, and timely referral of the patient to organized trauma centers ensure the best functional outcome of the extremity in such challenging cases. Even after a successful initial treatment of a combined trauma pattern, long-term follow-up is crucial to prevent and detect early possible complications. The purpose of this manuscript is to provide an update on diagnosis and treatment of combined musculoskeletal and vascular injuries of the extremities, from an orthopedic point of view.
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Affiliation(s)
- Nikolaos Stefanou
- Department of Orthopaedic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa 41500, Greece
| | - Christina Arnaoutoglou
- Department of Orthopaedic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa 41500, Greece
| | - Fotios Papageorgiou
- Department of Orthopaedic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa 41500, Greece
| | - Miltiadis Matsagkas
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa 41500, Greece
| | - Sokratis E Varitimidis
- Department of Orthopaedic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa 41500, Greece
| | - Zoe H Dailiana
- Department of Orthopaedic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa 41500, Greece
- Department of Hand, Upper Extremity and Microsurgery, IASO Thessalias, Larissa 41500, Greece
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Stopping extremity hemorrhage: More than just a tourniquet. Surg Open Sci 2022; 7:42-45. [PMID: 35028549 PMCID: PMC8741618 DOI: 10.1016/j.sopen.2021.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 11/11/2021] [Indexed: 11/21/2022] Open
Abstract
Major extremity hemorrhage is a surgical emergency, and the physical examination is essential to help dictate appropriate clinical decision making. Hard signs that require immediate surgical intervention include ongoing bleeding, expanding hematoma, ischemic limb, as well as partial/complete amputation. Packing, compression, balloon tamponade, and tourniquets are very helpful to temporize major hemorrhage. Mangled extremities are very challenging to manage and require a multidisciplinary approach. Temporary vascular shunts are excellent tools for vascular/orthopedic damage control and for temporary stabilization prior to transport for definitive care.
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Abstract
ABSTRACT This is a literature review on the history of venous trauma since the 1800s, especially that to the common femoral, femoral and popliteal veins, with focus on the early 1900s, World War I, World War II, Korean War, Vietnam War, and then civilian and military reviews (1960-2020). In the latter two groups, tables were used to summarize the following: incidence of venous repair versus ligation, management of popliteal venous injuries, patency of venous repairs when assessed <30 days from operation, patency of venous repairs when assessed >30 days from operation, clinical assessment (edema or not) after ligation versus repair, incidence of deep venous thrombosis after ligation versus repair, and incidence of pulmonary embolism after ligation versus repair.There is a lack of the following in the literature on the management of venous injuries over the past 80 years: standard definition of magnitude of venous injury in operative reports, accepted indications for venous repair, standard postoperative management, and timing and mode of early and later postoperative assessment.Multiple factors have entered into the decision on venous ligation versus repair after trauma for the past 60 years, but a surgeon's training and local management protocols have the most influence in both civilian and military centers. Ligation of venous injuries, particularly those in the lower extremities, is well tolerated in civilian trauma, although there is the usual lack of short- and long-term follow-up as noted in many of the articles reviewed. LEVEL OF EVIDENCE Review article, levels IV and V.
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Affiliation(s)
- David V Feliciano
- From the Department of Surgery (D.V.F.), Shock Trauma Center, University of Maryland Medical Center, University of Maryland, Baltimore, Maryland; Division of Acute Care Surgery, Department of Surgery (M.P.K.), University of Florida Health Jacksonville Medical Center, Jacksonville, Florida; and Division of Acute Care Surgery, Department of Surgery (G.F.R.), John Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Skarupa DJ, Kochuba MP, Feliciano DV. Arterial and venous injuries: the combined injury conundrum. Trauma Surg Acute Care Open 2021; 6:e000746. [PMID: 33907717 PMCID: PMC8051374 DOI: 10.1136/tsaco-2021-000746] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Affiliation(s)
- David J Skarupa
- Department of Surgery, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Matthew P Kochuba
- Department of Surgery, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
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American Association for the Surgery of Trauma-World Society of Emergency Surgery guidelines on diagnosis and management of peripheral vascular injuries. J Trauma Acute Care Surg 2021; 89:1183-1196. [PMID: 33230048 DOI: 10.1097/ta.0000000000002967] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The peripheral arteries and veins of the extremities are among the most commonly injured vessels in both civilian and military vascular trauma. Blunt causes are more frequent than penetrating except during military conflicts and in certain geographic areas. Physical examination and simple bedside investigations of pulse pressures are key in early identification of these injuries. In stable patients with equivocal physical examinations, computed tomography angiograms have become the mainstay of screening and diagnosis. Immediate open surgical repair remains the first-line therapy in most patients. However, advances in endovascular therapies and more widespread availability of this technology have resulted in an increase in the range of injuries and frequency of utilization of minimally invasive treatments for vascular injuries in stable patients. Prevention of and early detection and treatment of compartment syndrome remain essential in the recovery of patients with significant peripheral vascular injuries. The decision to perform amputation in patients with mangled extremities remains difficult with few clear indicators. The American Association for the Surgery of Trauma in conjunction with the World Society of Emergency Surgery seeks to summarize the literature to date and provide guidelines on the presentation, diagnosis, and treatment of peripheral vascular injuries. LEVEL OF EVIDENCE: Review study, level IV.
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Kochuba M, Rozycki GF, Feliciano D. Outcome after ligation of major veins for trauma. J Trauma Acute Care Surg 2021; 90:e40-e49. [PMID: 33502152 DOI: 10.1097/ta.0000000000003014] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Matthew Kochuba
- From the Division of Acute Care Surgery, Department of Surgery, UF Health Jacksonville Medical Center (M.K.), University of Florida-Jacksonville, Jacksonville, Florida; Division of Acute Care and Adult Trauma Surgery, Department of Surgery, Johns Hopkins University School of Medicine (G.F.R.), Johns Hopkins University; and Division of Surgical Critical Care, Department of Shock Trauma Center, Shock Trauma Center (D.F.), University of Maryland Medical Center, University of Maryland, Baltimore, Maryland
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10
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Evaluation of peripheral vascular injuries treated with surgery: A retrospective cohort study. JOURNAL OF SURGERY AND MEDICINE 2020. [DOI: 10.28982/josam.729546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Byerly S, Cheng V, Plotkin A, Matsushima K, Inaba K, Magee GA. Impact of ligation versus repair of isolated popliteal vein injuries on in-hospital outcomes in trauma patients. J Vasc Surg Venous Lymphat Disord 2019; 8:437-444. [PMID: 31843477 DOI: 10.1016/j.jvsv.2019.09.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 09/16/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Popliteal vascular injuries are common and frequently associated with limb loss. Although many studies have evaluated the treatment and outcomes of popliteal artery injuries (PAI), there is little available evidence regarding popliteal venous injuries (PVI). As such, substantial debate remains regarding the benefit of repair over ligation of PVI. The objectives of this study were to compare in-hospital outcomes of repair versus ligation of isolated PVI, as well as to determine nonvascular factors associated with worse outcomes. METHODS Patients in the National Trauma Databank from 2007 to 2014 with at least one PVI were evaluated. First, patients with concomitant PVI and PAI were compared with patients with isolated PVI. Second, outcomes were compared between ligation and repair of isolated PVI. To limit the impact of concomitant injuries and focus on the impact of venous injury management, we defined isolated PVI as cases without concomitant PAI and with Abbreviated Injury Scale severity score of less than 3 for all body regions other than lower extremity. Patients dead on arrival and those with less than 18 years of age were excluded. The primary outcomes were in-hospital mortality, amputation, and in-hospital amputation-free survival (AFS). Secondary outcomes included lower extremity compartment syndrome, fasciotomy, acute kidney injury, pulmonary embolism, deep venous thrombosis, and inferior vena cava filter placement. RESULTS Overall, 1819 patients (0.03%) had a PVI and after exclusion 1213 met the criteria for initial analysis. Of those, 308 had isolated PVI, and 905 had combined PVI and PAI. Patients with combined PVI and PAI had higher rates of amputation (15.2% vs 6.8%; P < .001), fasciotomy (64.5% vs 30.8%; P < .001), compartment syndrome (14.8% vs 8.8%; P = .006), and a lower AFS (82.9% vs 91.8%; P < .001) than patients with isolated PVI. There was no difference in in-hospital mortality, amputation, or in-hospital AFS between ligation and repair of isolated PVI. On multivariable logistic regression of isolated PVI, ligation was not independently associated with in-hospital AFS, amputation, or mortality. CONCLUSIONS Ligation of isolated PVI was not an independent predictor of in-hospital mortality, lower extremity amputation, or in-hospital AFS. Ligation also did not result in higher rates of fasciotomy, acute kidney injury, or pulmonary embolism.
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Affiliation(s)
- Saskya Byerly
- Division of Trauma and Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Fla
| | - Vincent Cheng
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif
| | - Anastasia Plotkin
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif
| | - Kazuhide Matsushima
- Division of Trauma and Critical Care, Department of Surgery, Keck School of Medicine, Los Angeles County Hospital, Los Angeles, Calif
| | - Kenji Inaba
- Division of Trauma and Critical Care, Department of Surgery, Keck School of Medicine, Los Angeles County Hospital, Los Angeles, Calif
| | - Gregory A Magee
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif.
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Feliciano DV. Leftovers. Trauma Surg Acute Care Open 2018; 3:e000273. [PMID: 30539158 PMCID: PMC6263419 DOI: 10.1136/tsaco-2018-000273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- David V Feliciano
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Leclerc B, Boyer E, Menu G, Leclerc G, Sergent P, Ducroux E, Salomon Du Mont L, Garbuio P, Rinckenbach S, Obert L. Two-team management of vascular injuries concomitant with osteo-articular injuries in 36 patients over six years. Orthop Traumatol Surg Res 2018; 104:497-502. [PMID: 29578106 DOI: 10.1016/j.otsr.2018.02.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 02/02/2018] [Accepted: 02/06/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Patients with both vascular and osteoarticular injuries require multidisciplinary management. Vascular injuries may be function- and/or life-threatening. The lower limbs are predominantly affected. Traffic, domestic, and work-related accidents contribute most of the cases. The primary objective of this study was to describe the management of patients with concomitant vascular and osteo-articular injuries, with special attention to the rates of amputation and fasciotomy. The secondary objective was to suggest a management sequence to optimise our surgical practice. HYPOTHESIS The management sequence is a crucial consideration in patients with both vascular and osteo-articular injuries. MATERIAL AND METHODS A 6-year, retrospective, observational study was conducted in patients with concomitant vascular and osteo-articular injuries. RESULTS The study included 36 patients with a mean age of 40.6±22.1 years. The main sources of injury were traffic accidents (n=19, 52.8%), crush injury (n=8, 22.2%), and falls (n=5, 13.9%). A compound fracture was present in 20 (55.6%) patients. Evidence of ischaemia in 25 (69.4%) patients, and bleeding in 11 (30.6%) patients. Pre-operative imaging, by ultrasonography or computed tomography, was performed in 27 (75.0%) patients. The lower limb was involved in 30 (83.3%) patients, who had osteoarticular injuries to the femur and leg combined with injury to the popliteal artery. Fasciotomy was performed in 11 (30.6%) patients and secondary amputation in 7 (19.4%) patients. The limb salvage rate was 80.6%. Median patient survival was 9.3 [0-74.8] months. DISCUSSION Coordinated work by two surgical teams is crucial to manage concomitant vascular and osteo-articular injuries. The management sequence must be defined clearly. Computed tomography angiography is the investigation of choice and should be performed at the slightest suspicion of vascular injury. LEVEL OF EVIDENCE IV, retrospective observational study.
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Affiliation(s)
- B Leclerc
- Service de chirurgie vasculaire et endovasculaire, hôpital Jean Minjoz, centre hospitalier universitaire, 3, boulevard Alexandre-Fleming, 25030 Besançon cedex, France; EA 3920, université de Franche-Comté, 25000 Besançon, France.
| | - E Boyer
- Service de chirurgie orthopédique , traumatologique, de chirurgie plastique, reconstructrice et assistance main, hôpital Jean-Minjoz, centre hospitalier universitaire, 3, boulevard Alexandre-Fleming, 25030 Besançon cedex, France; EA Nano Médecine-FEMTO, 25000 Besançon, France
| | - G Menu
- Service de chirurgie orthopédique , traumatologique, de chirurgie plastique, reconstructrice et assistance main, hôpital Jean-Minjoz, centre hospitalier universitaire, 3, boulevard Alexandre-Fleming, 25030 Besançon cedex, France; EA Nano Médecine-FEMTO, 25000 Besançon, France
| | - G Leclerc
- Service de chirurgie orthopédique , traumatologique, de chirurgie plastique, reconstructrice et assistance main, hôpital Jean-Minjoz, centre hospitalier universitaire, 3, boulevard Alexandre-Fleming, 25030 Besançon cedex, France; EA Nano Médecine-FEMTO, 25000 Besançon, France
| | - P Sergent
- Service de chirurgie orthopédique , traumatologique, de chirurgie plastique, reconstructrice et assistance main, hôpital Jean-Minjoz, centre hospitalier universitaire, 3, boulevard Alexandre-Fleming, 25030 Besançon cedex, France; EA Nano Médecine-FEMTO, 25000 Besançon, France
| | - E Ducroux
- Service de chirurgie vasculaire et endovasculaire, hôpital Jean Minjoz, centre hospitalier universitaire, 3, boulevard Alexandre-Fleming, 25030 Besançon cedex, France; EA 3920, université de Franche-Comté, 25000 Besançon, France
| | - L Salomon Du Mont
- Service de chirurgie vasculaire et endovasculaire, hôpital Jean Minjoz, centre hospitalier universitaire, 3, boulevard Alexandre-Fleming, 25030 Besançon cedex, France; EA 3920, université de Franche-Comté, 25000 Besançon, France
| | - P Garbuio
- Service de chirurgie orthopédique , traumatologique, de chirurgie plastique, reconstructrice et assistance main, hôpital Jean-Minjoz, centre hospitalier universitaire, 3, boulevard Alexandre-Fleming, 25030 Besançon cedex, France; EA Nano Médecine-FEMTO, 25000 Besançon, France
| | - S Rinckenbach
- Service de chirurgie vasculaire et endovasculaire, hôpital Jean Minjoz, centre hospitalier universitaire, 3, boulevard Alexandre-Fleming, 25030 Besançon cedex, France; EA 3920, université de Franche-Comté, 25000 Besançon, France
| | - L Obert
- Service de chirurgie orthopédique , traumatologique, de chirurgie plastique, reconstructrice et assistance main, hôpital Jean-Minjoz, centre hospitalier universitaire, 3, boulevard Alexandre-Fleming, 25030 Besançon cedex, France; EA Nano Médecine-FEMTO, 25000 Besançon, France
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Impact of venorrhaphy and vein ligation in isolated lower-extremity venous injuries on venous thromboembolism and edema. J Trauma Acute Care Surg 2018; 84:325-329. [DOI: 10.1097/ta.0000000000001746] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
BACKGROUND Venous thromboembolism (VTE) after major vascular injury (MVI) is particularly challenging because the competing risk of thrombosis and embolization after direct vessel injury must be balanced with risk of bleeding after surgical repair. We hypothesized that venous injuries, repair type, and intraoperative anticoagulation would influence VTE formation after MVI. METHODS A multi-institution, retrospective cohort study of consecutive MVI patients was conducted at three urban, Level I centers (2005-2013). Patients with MVI of the neck, torso, or proximal extremities (to elbows/knees) were included. Our primary study endpoint was the development of VTE (DVT or pulmonary embolism [PE]). RESULTS The 435 major vascular injury patients were primarily young (27 years) men (89%) with penetrating (84%) injuries. When patients with (n = 108) and without (n = 327) VTE were compared, we observed no difference in age, mechanism, extremity injury, tourniquet use, orthopedic and spine injuries, damage control, local heparinized saline, or vascular surgery consultation (all p > 0.05). VTE patients had greater Injury Severity Score (ISS) (17 vs. 12), shock indices (1 vs. 0.9), and more torso (58% vs. 35%) and venous (73% vs. 48%) injuries, but less often received systemic intraoperative anticoagulation (39% vs. 53%) or postoperative enoxaparin (47% vs. 61%) prophylaxis (all p < 0.05). After controlling for ISS, hemodynamics, injured vessel, intraoperative anticoagulation, and postoperative prophylaxis, multivariable analysis revealed venous injury was independently predictive of VTE (odds ratio, 2.7; p = 0.002). Multivariable analysis of the venous injuries subset (n = 237) then determined that only delay in starting VTE chemoprophylaxis (odds ratio, 1.3/day; p = 0.013) independently predicted VTE after controlling for ISS, hemodynamics, injured vessel, surgical subspecialty, intraoperative anticoagulation, and postoperative prophylaxis. Overall, 3.4% of venous injury patients developed PE, but PE rates were not related to their operative management (p = 0.72). CONCLUSION Patients with major venous injuries are at high risk for VTE, regardless of intraoperative management. Our results support the immediate initiation of postoperative chemoprophylaxis in patients with major venous injuries. LEVEL OF EVIDENCE Therapeutic/care management, level IV.
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Affiliation(s)
- David V Feliciano
- Department of Surgery, University of Maryland School of Medicine and the Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD; and Battersby Professor of Surgery Emeritus; Chief Emeritus, Division of General Surgery, Indiana University School of Medicine, Indianapolis, IN.
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Feliciano DV. Pitfalls in the management of peripheral vascular injuries. Trauma Surg Acute Care Open 2017; 2:e000110. [PMID: 29766105 PMCID: PMC5877918 DOI: 10.1136/tsaco-2017-000110] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 05/12/2017] [Accepted: 05/13/2017] [Indexed: 01/17/2023] Open
Abstract
Over the past 65+ years, most civilian peripheral vascular injuries have been managed by trauma surgeons with training or experience in vascular repair or ligation. This is appropriate as the in-hospital trauma team is immediately available, and there are often other injuries present in the victim. The pitfall to avoid during evaluation of the patient in the emergency center is a missed diagnosis. In the patient without ‘hard’ signs of a peripheral vascular injury, a careful history (bleeding), physical examination including measurement of ankle–brachial (ABI) or brachial–brachial index and liberal use of CT arteriography depending on an ABI <0.9 should essentially make the diagnosis if an arterial injury is present. At operation, one pitfall is to limit skin preparation and draping, thereby eliminating the option of removing the greater saphenous vein if needed as a conduit from either the groin or ankle of an uninjured lower extremity. Another pitfall is to make a full longitudinal incision directly over a large pulsatile hematoma. Rather, separate shorter longitudinal incisions should be made to obtain proximal and distal vascular control before entering the hematoma. The failure to recognize patients who should be managed initially with insertion of a temporary intraluminal shunt is a major pitfall as well. Not following time-proven and results-proven ‘fine techniques’ of operative repair is another major pitfall. Such techniques include the following: use of small angioaccess vascular clamps or silastic vessel loops; passage of proximal and distal Fogarty catheters; administration of regional or systemic heparin during complex repairs; an open anastomosis technique; and completion arteriography after a complex arterial repair in a lower extremity. Avoiding pitfalls should allow for success in peripheral vascular repair, particularly since most patients are young with non-diseased vessels.
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Affiliation(s)
- David V Feliciano
- Division of General Surgery, Indiana University Medical Center, Indianapolis, Indiana, USA
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Giannakopoulos TG, Avgerinos ED. Management of Peripheral and Truncal Venous Injuries. Front Surg 2017; 4:46. [PMID: 28884115 PMCID: PMC5573711 DOI: 10.3389/fsurg.2017.00046] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Accepted: 08/08/2017] [Indexed: 12/19/2022] Open
Abstract
Civilian injuries are increasing according to the World Health Organization, and this is attributed mainly to road traffic accidents and urban interpersonal violence. Vascular injuries are common in these scenarios and are associated with high morbidity and mortality rates. Associated peripheral venous trauma is less likely to lead to death and controversy remains whether ligation or repair should be the primary approach. Conversely, non-compressible truncal venous insult can be lethal due to exsanguination, thus a high index of suspicion is crucial. Operative management is demanding with fair results but recent endovascular adjuncts demonstrate promising results and seem to be the way forward for these serious conditions.
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Affiliation(s)
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
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Mavrogenis AF, Panagopoulos GN, Kokkalis ZT, Koulouvaris P, Megaloikonomos PD, Igoumenou V, Mantas G, Moulakakis KG, Sfyroeras GS, Lazaris A, Soucacos PN. Vascular Injury in Orthopedic Trauma. Orthopedics 2016; 39:249-59. [PMID: 27322172 DOI: 10.3928/01477447-20160610-06] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 11/30/2015] [Indexed: 02/03/2023]
Abstract
Vascular injury in orthopedic trauma is challenging. The risk to life and limb can be high, and clinical signs initially can be subtle. Recognition and management should be a critical skill for every orthopedic surgeon. There are 5 types of vascular injury: intimal injury (flaps, disruptions, or subintimal/intramural hematomas), complete wall defects with pseudoaneurysms or hemorrhage, complete transections with hemorrhage or occlusion, arteriovenous fistulas, and spasm. Intimal defects and subintimal hematomas with possible secondary occlusion are most commonly associated with blunt trauma, whereas wall defects, complete transections, and arteriovenous fistulas usually occur with penetrating trauma. Spasm can occur after either blunt or penetrating trauma to an extremity and is more common in young patients. Clinical presentation of vascular injury may not be straightforward. Physical examination can be misleading or initially unimpressive; a normal pulse examination may be present in 5% to 15% of patients with vascular injury. Detection and treatment of vascular injuries should take place within the context of the overall resuscitation of the patient according to the established principles of the Advanced Trauma Life Support (ATLS) protocols. Advances in the field, made mostly during times of war, have made limb salvage the rule rather than the exception. Teamwork, familiarity with the often subtle signs of vascular injuries, a high index of suspicion, effective communication, appropriate use of imaging modalities, sound knowledge of relevant technique, and sequence of surgical repairs are among the essential factors that will lead to a successful outcome. This article provides a comprehensive literature review on a subject that generates significant controversy and confusion among clinicians involved in the care of trauma patients. [Orthopedics. 2016; 39(4):249-259.].
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Current concepts in repair of extremity venous injury. J Vasc Surg Venous Lymphat Disord 2016; 4:238-47. [DOI: 10.1016/j.jvsv.2015.07.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 07/24/2015] [Indexed: 10/22/2022]
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Al-Ganadi A. Management of Vascular Injury during Current Peaceful Yemeni Revolution. Ann Vasc Surg 2015; 29:1575-80. [DOI: 10.1016/j.avsg.2015.06.075] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 06/28/2015] [Indexed: 10/23/2022]
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23
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Rattan R, Jones KM, Namias N. Management of Lower Extremity Vascular Injuries: State of the Art. CURRENT SURGERY REPORTS 2015. [DOI: 10.1007/s40137-015-0118-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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24
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To Shunt or Not to Shunt? An Experimental Study Comparing Temporary Vascular Shunts and Venous Ligation as Damage Control Techniques for Vascular Trauma. Ann Vasc Surg 2014; 28:710-24. [DOI: 10.1016/j.avsg.2013.10.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Revised: 10/02/2013] [Accepted: 10/07/2013] [Indexed: 11/24/2022]
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25
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Vascular complications and special problems in vascular trauma. Eur J Trauma Emerg Surg 2013; 39:569-89. [DOI: 10.1007/s00068-013-0336-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Accepted: 09/30/2013] [Indexed: 12/17/2022]
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Ekim H, Basel H, Odabasi D. Management of traumatic popliteal vein injuries. Injury 2012; 43:1482-5. [PMID: 21310407 DOI: 10.1016/j.injury.2011.01.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2010] [Revised: 10/08/2010] [Accepted: 01/17/2011] [Indexed: 02/02/2023]
Abstract
PURPOSE The aim of this study was to evaluate different repair methods of popliteal vein injuries, and to assess the relationship between early patency and surgical outcome. METHODS Thirty patients with popliteal vein injuries underwent surgical repair procedure at our hospital from March 2000 to April 2010. Patients who were haemodynamically unstable and those with massive bleeding from limb wounds were taken directly to the operating room. Stable patients underwent preoperative colour-flow duplex ultrasonography (CFDU). RESULTS Our study group consisted of 26 males and 4 females, ranging in age from 17 to 60 years with a mean age of 25.3 ± 5.9 years. The mechanism of trauma was penetrating in 27 patients and blunt in the remaining 3 patients. Treatment included primary venous repair in 11 cases, end-to-end anastomosis in 8, interposition vein graft in 10, and interposition polytetrafluoroethylene (PTFE) graft in 1. There were 26 patients with associated arterial injury, of which 4 cases had primary repair, 9 had end-to-end anastomosis, 11 had saphenous vein graft interposition, and 2 had PTFE graft interposition. Associated bone fracture was seen in 6 patients. There were no deaths. One patient required a below-knee amputation. Postoperative CFDU revealed thrombosed venous repair in 7 cases without any sequelae. CONCLUSION Popliteal venous injuries can be repaired with minimal downside and a good early patency rate. Additionally, transient venous patency allows for establishment of venous and lymphatic collateralisation. Alternatively, venous ligation should be considered only in unstable patients who refuse blood transfusion (Jehovah's witnesses). In these victims, adjuvant management may be required such as the use of fasciotomy and anticoagulation treatment.
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Affiliation(s)
- Hasan Ekim
- Yüzüncü Yıl University, Department of Cardiovascular Surgery, Van, Turkey.
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Stovall RT, Pieracci FM, Johnson JL. Perioperative Management of Peripheral Vascular Trauma. Semin Cardiothorac Vasc Anesth 2012; 16:133-41. [DOI: 10.1177/1089253212445929] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Peripheral vascular trauma is not uncommon in the civilian setting, and it can be uniquely challenging because of the limited time during which intervention can salvage an ischemic extremity. Injuries can be from a blunt or penetrating mechanism, and these injuries can be isolated or can be in the setting of a complex multisystem trauma. The intent of this review is to discuss the perioperative management of peripheral vascular trauma with an emphasis of predicting, preventing, and managing common postoperative complications.
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Prolonged indwelling time of temporary vascular shunts is associated with increased endothelial injury in the porcine mesenteric artery. ACTA ACUST UNITED AC 2011; 70:1464-70. [PMID: 21817984 DOI: 10.1097/ta.0b013e31820c9b4e] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Temporary intravascular shunts (TIVS) have been used as a damage control surgery (DCS) adjuncts in superior mesenteric artery (SMA) injuries, both experimentally and clinically. However, no study to date has evaluated the relationship between shunt indwelling time and resultant endothelial cell (EC) injury. We hypothesized that prolonged use of TIVS in SMA injuries would jeopardize EC integrity. METHOD After laparotomy, the SMA was clamped and transected while pigs were hemorrhaged to 40 mm Hg for 30 minutes. A TIVS was inserted between transected ends of the SMA without systemic anticoagulation. Totally, 24 animals were resuscitated and randomized to different shunt indwelling time groups: A, 3 hours; B, 6 hours; C, 9 hours; and D, 12 hours. Patency of shunts was monitored and recorded. Continuous wave Doppler was used as a determinant of adequacy of flow through the shunts. Transmural SMA biopsies from areas of TIVS placement were examined with electron microscopy for histopathologic injury after staining with hematoxylin and eosin and immunofluorescence using a validated histopathologic injury score (minimum-maximum score: 0-4). RESULTS Severity of endothelial injury was observed to be directly related to shunt indwell time. SMA transmural biopsies harvested from group D animals showed the most profound injury, demonstrating extensive EC denudations and marked intimal rupture (injury grade, 3.4 ± 0.2). Sections from group A animals revealed the mildest EC injury (1.3 ± 0.3 vs. group D p < 0.01). No significant difference was detected between group A and B. EC injury grade in group C (2.7 ± 0.6) was higher than that in group B (1.8 ± 0.6) but did not reach statistical significance (p = 0.58). CONCLUSION When possible, vascular reconstruction following use of shunts should include an interposition graft after debridement of the arterial edges having interfaced with the shunt. Finally, to minimize intimal injury to the native vessel, this model suggests that indwell times of shunts should be <9 hours.
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Tofigh A, Karvandi M. Incidence and Outcome of Pulmonary Embolism following Popliteal Venous Repair in Trauma Cases. Eur J Vasc Endovasc Surg 2011; 41:406-11. [DOI: 10.1016/j.ejvs.2010.11.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2010] [Accepted: 11/27/2010] [Indexed: 11/26/2022]
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The use of temporary vascular shunts in military extremity wounds: a preliminary outcome analysis with 2-year follow-up. ACTA ACUST UNITED AC 2010; 69:174-8. [PMID: 20622589 DOI: 10.1097/ta.0b013e3181e03e71] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND The use of temporary vascular shunts (TVS)s in the management of wartime extremity vascular injuries has received an increasing amount of attention. However, the overall impact of this adjunct remains incompletely defined. The objective of this study is to characterize outcomes of those patients who suffered wartime extremity vascular injuries managed with TVSs. METHODS This is a retrospective review of the Navy and Marine Corps Combat Trauma Registry examining peripheral vascular injuries treated during the military conflicts in the Middle East. Patient demographics, injury severity score, mechanism of injury, and vessels injured were recorded. Operative reports were reviewed for use of TVSs, type of definitive repair, the need for amputation, and survival. RESULTS Eighty patients were included. Forty-six (57%) had TVSs placed and 34 (43%) underwent repair at initial presentation. The mean injury severity score for the TVS group and the non-TVS groups were 15.0 +/- 5.05 and 12.9 +/- 10.18, respectively, (p = 0.229). There were a total of 13 amputations, 6 (13%) in the TVS group and 7 (21%) in the non-TVS group (p = 0.38). There was no difference in amputation rates between either group. There were no recorded mortalities in either group. Median patient follow-up was 24.5 months (range, 3-48 months). CONCLUSIONS This study demonstrates the importance and utility of TVSs in the management of wartime extremity vascular injury. When used to restore perfusion to an injured extremity, there seems to be no adverse effects or overall increase in limb loss rates and therefore a useful adjunct in the surgery for limb salvage.
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Ozeki K, Nagashima I, Hirakuri KK, Masuzawa T. Adsorptive properties of albumin, fibrinogen, and gamma-globulin on fluorinated diamond-like carbon films coated on PTFE. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2010; 21:1641-1648. [PMID: 20101441 DOI: 10.1007/s10856-010-3994-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2009] [Accepted: 01/08/2010] [Indexed: 05/28/2023]
Abstract
Fluorinated diamond-like carbon (F-DLC) films were deposited on polytetrafluoroethylene (PTFE) using radio frequency (RF) plasma-enhanced chemical vapor deposition (CVD) by changing the ratio of tetrafluoromethane (CF(4)) and methane (CH(4)). To enhance the adhesion strength of the F-DLC film to the PTFE substrate, the PTFE surface was modified with a N(2) plasma pre-treatment. XPS analysis of the films showed that the C-C bond decreased with increases in the CF(4) ratio, whereas the C-F bond increased with the CF(4) ratio. The F/C ratio of the film also increased with the CF(4) ratio. The pull-out test showed that the adhesion strengths of the films (CF(4)-0-60%) were improved with the plasma pre-treatment. In the film without the plasma pre-treatment, adhesion strength increased with the CF(4) ratio. In contrast, in the case with the plasma pre-treatment, the adhesion strength of the F-DLC film decreased with the increased CF(4) ratio. Regarding the adsorption of albumin, fibrinogen, and gamma-globulin, the amount of adsorbed albumin on the film decreased with an increasing CF(4) ratio, and the amount of adsorbed fibrinogen and gamma-globulin increased with the CF(4) ratio. The CF(4)-0% DLC film showed the most adsorbed albumin and the least adsorbed fibrinogen and gamma-globulin. This indicates that the CF(4)-0% DLC film has higher anti-thrombogenicity than the F-DLC film.
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Affiliation(s)
- K Ozeki
- Department of Mechanical Engineering, Ibaraki University, 4-12-1, Nakanarusawa, Hitachi, Ibaraki, 316-8511, Japan.
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Ball CG, Kirkpatrick AW, Rajani RR, Wyrzykowski AD, Dente CJ, Vercruysse GA, Mcbeth P, Nicholas JM, Salomone JP, Rozycki GS, Feliciano DV. Temporary Intravascular Shunts: When Are We Really Using Them According to the NTDB? Am Surg 2009. [DOI: 10.1177/000313480907500712] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Temporary intravascular shunts (TIVS) are synthetic intraluminal conduits that maintain arterial and/or venous blood flow. This technique can be used for: 1) replantation; 2) open extremity fractures with extensive soft tissue and arterial injuries; or 3) damage control (extremity/truncal). The literature defining TIVS is composed exclusively of small case series (primarily penetrating injuries). Our goal was to identify the injured population who actually undergoes TIVS using the National Trauma Data Bank (2001 to 2005). TIVS were placed in 395 patients (mean Injury Severity Score = 26; initial hemodynamic instability = 24%; mean based deficit = –7.2; mortality = 14%). Blunt mechanisms caused 64 per cent (251 of 395) of cases. Penetrating injuries were primarily gunshot wounds (97%). Concurrent severe extremity fractures and/or soft tissue defects were present in 185 (74%) blunt-injured patients. Only six of 111 centers performing TIVS used this technique five or more times. Only three centers used TIVS more than 10 times. The volume of TIVS use was similar across the study period ( P > 0.05). TIVS is primarily used in blunt motor vehicle collision trauma with concurrent severe extremity fractures and soft tissue injuries. This provides distal perfusion while surgeons assess/fixate the limb. TIVS are placed relatively uncommonly by a large number of trauma centers with a few hospitals using them much more frequently for penetrating injuries.
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Affiliation(s)
- Chad G. Ball
- Department of Surgery, Emory School of Medicine, Grady Memorial Hospital, Atlanta, Georgia
| | - Andrew W. Kirkpatrick
- Department of Surgery, Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Trauma, Foothills Medical Centre, Calgary, Alberta, Canada
- Critical Care Medicine, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Ravi R. Rajani
- Department of Surgery, Emory School of Medicine, Grady Memorial Hospital, Atlanta, Georgia
| | - Amy D. Wyrzykowski
- Department of Surgery, Emory School of Medicine, Grady Memorial Hospital, Atlanta, Georgia
| | - Christopher J. Dente
- Department of Surgery, Emory School of Medicine, Grady Memorial Hospital, Atlanta, Georgia
| | - Gary A. Vercruysse
- Department of Surgery, Emory School of Medicine, Grady Memorial Hospital, Atlanta, Georgia
| | - Paul Mcbeth
- Department of Surgery, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Jeffrey M. Nicholas
- Department of Surgery, Emory School of Medicine, Grady Memorial Hospital, Atlanta, Georgia
| | - Jeffrey P. Salomone
- Department of Surgery, Emory School of Medicine, Grady Memorial Hospital, Atlanta, Georgia
| | - Grace S. Rozycki
- Department of Surgery, Emory School of Medicine, Grady Memorial Hospital, Atlanta, Georgia
| | - David V. Feliciano
- Department of Surgery, Emory School of Medicine, Grady Memorial Hospital, Atlanta, Georgia
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Temporary intravascular shunts used as a damage control surgery adjunct in complex vascular injury: collective review. Injury 2008; 39:970-7. [PMID: 18407275 DOI: 10.1016/j.injury.2008.01.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2007] [Accepted: 01/02/2008] [Indexed: 02/02/2023]
Abstract
In this systemic review, we summarise the types, configurations, durations, indications and complications of the temporary intravascular shunts used as an adjunct of damage control surgery (DCS) in severe vascular injuries. We conclude that temporary intravascular shunts can be used without systemic anticoagulation for a prolonged time to maintain distal perfusion in combined orthopaedic and vascular injuries, in the setting of DCS and transferring.
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Suliman A, Ali MW, Kansal N, Tian Y, Angle N, Coimbra R. Complete femoral artery and vein avulsion from a hyperextension injury: a case report and literature review. Ann Vasc Surg 2008; 23:411.e9-15. [PMID: 18619776 DOI: 10.1016/j.avsg.2008.05.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2007] [Revised: 03/11/2008] [Accepted: 05/08/2008] [Indexed: 10/21/2022]
Abstract
Blunt peripheral extremity vascular injuries are much less frequent than those of penetrating injuries, especially in the absence of significant musculoskeletal trauma. We present an unusual case of complete femoral artery and vein avulsion that resulted from a forced hip hyperextension and thigh abduction after slipping when a patient's foot became entrapped in a ladder. The patient presented with an acutely ischemic right lower extremity 8 hr postinjury, which necessitated immediate surgical exploration, temporary intravascular shunting, interposition grafting, and prophylactic fasciotomy. To our knowledge, this is the first such mechanism to be reported resulting in complete transection of both femoral artery and vein. We review the mechanism of injury and management.
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Affiliation(s)
- Ahmed Suliman
- Department of Surgery, University of California, San Diego School of Medicine, UCSD Medical Center, San Diego, CA 92103-8896, USA
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Quan RW, Gillespie DL, Stuart RP, Chang AS, Whittaker DR, Fox CJ. The effect of vein repair on the risk of venous thromboembolic events: a review of more than 100 traumatic military venous injuries. J Vasc Surg 2008; 47:571-7. [PMID: 18295108 DOI: 10.1016/j.jvs.2007.10.056] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2007] [Revised: 10/16/2007] [Accepted: 10/18/2007] [Indexed: 11/15/2022]
Abstract
BACKGROUND The management of venous trauma remains controversial. Critics of venous repair have cited an increased incidence of associated venous thromboembolic events with this management. We analyzed the current treatment of wartime venous injuries in United States military personnel in an effort to answer this question. METHODS From December 1, 2001, to October 31, 2005, all United States casualties with named venous injuries were evaluated. A retrospective review of a clinical database was performed on demographics, mechanism of injury, associated injuries, treatment, outcomes, and venous thromboembolic events. Data were analyzed using the Fisher exact test, analysis of variance, and logarithmic transformation. RESULTS During this 5-year period, 82 patients sustained 103 named venous injuries due to combat operations. All patients were male, with an average age of 27.9 years (range, 20.3-58.3 years). Blast injuries accounted for 54 venous injuries (65.9%), gunshot wounds for 25 (30.5%), and motor vehicle accidents for 3 (3.6%). The venous injury was isolated in 28 patients (34.1%), and 16 (19.5%) had multiple venous injuries. The venous injury in two patients was associated with acute phlegmasia, with fractures in 33 (40.2%), and 22 (28.1%) sustained neurologic deficits. Venous injuries were treated by ligation in 65 patients (63.1%) and by open surgical repair in 38 (36.9%). Postoperative extremity edema occurred in all patients irrespective of method of management. Thrombosis after venous repair occurred in six of the 38 cases (15.8%). Pulmonary emboli developed in three patients, one after open repair and two after ligation (P > .99). CONCLUSION In the largest review of military venous trauma in more than three decades, we found no difference in the incidence of venous thromboembolic complications between venous injuries managed by open repair vs ligation. Blast injuries of the extremities have caused most of the venous injuries. Ligation is the most common modality of treatment in combat zones. Long-term morbidity associated with venous injuries and their management will be assessed in future follow-up studies.
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Affiliation(s)
- Reagan W Quan
- Division of Vascular and Endovascular Surgery, Department of Surgery, Walter Reed Army Medical Center, Washington, DC 20307, USA.
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Leon LR, Hughes JD, Psalms SB, Guerra R, Biswas A, Prasad A, Krouse RS. Portomesenteric reconstruction during Whipple procedures: review and report of a case. Vasc Endovascular Surg 2008; 41:537-46. [PMID: 18166637 DOI: 10.1177/1538574407305019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A 60-year-old man undergoing a Whipple procedure to treat a pancreatic cancer was found to have tumor adherence to the portal vein. An en block pancreaticoduodenectomy with segmental portal vein resection (PVR) was performed. A primary portal vein anastomosis was initially attempted but failed. Hemodynamic deterioration led the authors to perform a temporary prosthetic portal vein interposition graft and abdominal closure. The following morning, once stable, the patient was brought back to the operating room for autologous reconstruction with femoral vein and completion of the pancreaticoduodenectomy. The role of PVR for vein invasion or tumor adherence during a Whipple procedure is still under debate. However, there is growing evidence that the perioperative morbidity and long-term survival in patients who undergo a pancreaticoduodenectomy with PVR are similar to those of patients without vein resection. Therefore a combined resection of the pancreatic head and the portal vein has been suggested in the absence of other contraindications for resection to be able to offer a curative surgical intervention to a larger number of patients. The authors herein report the details of a patient's case and also review the currently available methods for PVR and reconstruction.
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Affiliation(s)
- Luis R Leon
- Southern Arizona Veterans Affairs Health Care System, University of Arizona Health Science Center Tucson, Arizona 85723, USA.
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Acute venous disease: Venous thrombosis and venous trauma. J Vasc Surg 2007; 46 Suppl S:25S-53S. [DOI: 10.1016/j.jvs.2007.08.037] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2006] [Revised: 08/15/2007] [Accepted: 08/19/2007] [Indexed: 10/22/2022]
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Abstract
Management of lower extremity venous trauma using repair or ligation has been an area of controversy during the past decades. However, in unstable patients or if primary repair is technically impossible as a result of extensive disruption of the vein, ligation is recommended. This study investigated the effects of venous ligation on major veins in the lower extremities when primary repair is impossible as a result of extensive laceration of the vein. Between January 2001 and April 2004, 63 patients with Grade III and IV venous injuries were observed prospectively. Compression ultrasonography was performed postoperatively on the fifth day, once before discharge, and at the 3-month visit to assess deep vein thrombosis (DVT) and the patency of arterial repair. If DVT was present, the patient was given an oral anticoagulant (warfarin Na) for 3 months (international normalized ratio, 2.0–3.0), and Class II compression stockings (Sigvaris-212, Ganzoni, Switzerland) were used for 1 year. Follow-up visits occurred at 1, 3, 6, and 12 months and at 6-month intervals thereafter. Combined arterial and venous injuries were present in 50 (79.4%) patients and pure venous injuries were present in 13 (20.6%) patients. DVT developed in 49 patients (77.7%; postoperative n = 37 [58.7%], late n = 12 [19%]). Three arterial restenoses (4.7%) and one pseudoaneurysm (1.6%) of the superficial femoral artery developed. Five early (prophylactic) and two late (compartment syndrome) fasciotomies were performed. Postoperative edema was seen in 56 (88.8%) patients and wound infection was seen in 19 patients (30.1%; n = 18 superficial, n = 1 deep). Two amputations (3.2%) were performed. One patient (1.7%) died as a result of irreversible shock. After a median of 18 months, 25 patients were classified with Clinical Etiology, Anatomy, Pathology classification: 10 legs C-0, seven legs C-2, and eight legs C-3. No severe postthrombophlebitic syndrome was observed. Early leg swelling after venous ligation was the most common morbidity. We observed no significant sequelae of chronic venous insufficiency, and venous ligation had no detrimental effect on associated arterial repair. In cases of DVT, anticoagulation with low-molecular-weight heparin and oral anticoagulants should begin immediately and continue for 3 months along with compression stocking support for 1 year.
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Toursarkissian B, Corneille M, Hagino RT, Stewart R. Use of ipsilateral superficial femoral vein for common femoral vein reconstruction after trauma: A useful approach in selected cases. THE JOURNAL OF TRAUMA 2006; 61:732-4; discussion 735. [PMID: 16967015 DOI: 10.1097/01.ta.0000196313.57011.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Affiliation(s)
- Boulos Toursarkissian
- Division of Vascular Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas 78229, USA.
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Goz M, Cakir O, Eren N. Peripheral vascular injuries due to firearms in children. Eur J Vasc Endovasc Surg 2006; 32:690-5. [PMID: 16872850 DOI: 10.1016/j.ejvs.2006.06.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2006] [Accepted: 06/14/2006] [Indexed: 11/21/2022]
Abstract
BACKGROUND Vascular injuries caused by firearms are rare among children. In this paper we discuss the surgical methods of treating peripheral vascular injuries due to firearms in children. MATERIALS AND METHODS Forty-four patients with peripheral vascular injuries due to firearms were included in this retrospective study. The patients were under the age of 14 and treated in our clinic between January 1985 and December 2004. RESULTS Vascular injuries due to firearms in children made up 4.9% of all cases of vascular trauma in our clinic. The male to female ratio was 38:6, and the age range was 3-14. The survival rate was 98% and the rate of limb salvage was 91%. For arterial and venous injuries, a saphenous vein interposition graft and interrupted sutures were often preferred surgically. CONCLUSION Peripheral vascular injuries due to firearms in children and other accompanying traumas can be easily identified and treated, and have low morbidity and mortality with an acceptable limb salvage rate if a rapid and effective approach is used.
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Affiliation(s)
- M Goz
- Dicle University School of Medicine, Cardiovascular Surgery, Diyarbakir, Turkey.
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Jeroukhimov I, Altshuler A, Peer A, Bass A, Halevy A. Endovascular stent-graft is a good alternative to traditional management of subclavian vein injury. THE JOURNAL OF TRAUMA 2004; 57:1329-30. [PMID: 15625470 DOI: 10.1097/01.ta.0000151272.19438.60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Affiliation(s)
- Igor Jeroukhimov
- Division of Surgery, Assaf Harofeh Medical Center, Zerifin, affiliated to Sackler Faculty of Medicine, Tel Aviv University, Israel
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Rozycki GS. What’s new in trauma and critical care. J Am Coll Surg 2004; 198:798-805. [PMID: 15110814 DOI: 10.1016/j.jamcollsurg.2004.01.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2004] [Accepted: 01/23/2004] [Indexed: 10/26/2022]
Affiliation(s)
- Grace S Rozycki
- Department of Surgery, Emory University School of Medicine, Grady Memorial Hospital, 69 Jesse Hill Jr. Drive, Room 302, Atlanta, GA 30303, USA
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