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Harting MT, Drucker NA, Austin MT, Greives MR, Cotton BA, Wang SK, Williams DP, DuBose JJ, Cox CS. Principles and Practice in Pediatric Vascular Trauma: Part 1: Scope of Problem, Team Structure, Multidisciplinary Dynamics, and Solutions. J Pediatr Surg 2024:161654. [PMID: 39181780 DOI: 10.1016/j.jpedsurg.2024.07.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2024] [Accepted: 07/25/2024] [Indexed: 08/27/2024]
Abstract
As of 2020, penetrating injuries became the leading cause of death among children and adolescents ages 1-19 in the United States. For the patients who initially survive and receive advanced medical care, vascular injuries are a significant cause of morbidity and additionally trigger notable trauma team angst. Moreover, penetrating injuries can lead to life-threatening hemorrhage and/or limb-threatening ischemia if not addressed promptly. Vascular injury management demands timely and unique expertise, particularly for pediatric patients. As the frequency of vascular injuries requiring operative management increases, it becomes clear that an ad hoc approach is not ideal. An integrated team would provide the best approach for rapid hemorrhage control and revascularization, but the structure of vascular response teams at children's hospitals is highly variable. In part 1 of this review, we will evaluate the scope and extent of the epidemic of traumatic vascular injuries in pediatric patients, review current evidence and outcomes, discuss various challenges and advantages of different team structures, and outline potential outcome targets and pediatric vascular trauma response solutions. LEVEL OF EVIDENCE: n/a.
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Affiliation(s)
- Matthew T Harting
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center, Houston, TX, USA; Red Duke Trauma Institute at Memorial Hermann - Texas Medical Center, Houston, TX, USA; Children's Memorial Hermann Hospital, Houston, TX, USA.
| | - Natalie A Drucker
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center, Houston, TX, USA
| | - Mary T Austin
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center, Houston, TX, USA; Red Duke Trauma Institute at Memorial Hermann - Texas Medical Center, Houston, TX, USA
| | - Matthew R Greives
- Children's Memorial Hermann Hospital, Houston, TX, USA; Department of Surgery, Division of Plastic Surgery, McGovern Medical School at The University of Texas Health Science Center, Houston, TX, USA
| | - Bryan A Cotton
- Red Duke Trauma Institute at Memorial Hermann - Texas Medical Center, Houston, TX, USA; Department of Surgery, Division of Acute Care Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - S Keisin Wang
- Department of Cardiothoracic and Vascular Surgery, Division of Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center, Houston, TX, USA; Heart and Vascular Institute, Memorial Hermann - Texas Medical Center, Houston, TX, USA
| | - Derrick P Williams
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center, Houston, TX, USA
| | - Joseph J DuBose
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Charles S Cox
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center, Houston, TX, USA; Red Duke Trauma Institute at Memorial Hermann - Texas Medical Center, Houston, TX, USA; Children's Memorial Hermann Hospital, Houston, TX, USA.
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Hussein AM, Ali AA, Ahmed SA, Mohamud MFY, Ahmed MAM, Kizilay M. Our experience with blast and gunshot induced traumatic vascular injuries at Somalia's major vascular referral center. Sci Rep 2024; 14:13004. [PMID: 38844514 PMCID: PMC11156839 DOI: 10.1038/s41598-024-63686-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 05/31/2024] [Indexed: 06/09/2024] Open
Abstract
Blast and gunshot-induced penetrating traumatic vascular injuries represent a significant portion of patients with vascular trauma in countries where there are higher rates of war-related violence. These injuries are especially challenging in resource-limited countries due to early diagnosis and transfer delays. This report aimed to present our experience regarding the surgical management and outcome of such injuries at a major referral vascular surgery centre in the country. A retrospective descriptive review of 326 patients with blast and gunshot-induced penetrating traumatic vascular injuries managed during a five-year period between April 2018 and April 2023. The demographics, mechanism of injury, type of vascular injury, Anatomical location, time to the operation, length of hospital stay, amount of blood products given, concomitant neuroskeletal injuries, development of Vascular injury associated acute kidney injury, surgical procedures performed and patient outcome were reviewed. In this study, 326 patients with 445 vascular injuries fulfilled the inclusion criteria. Most of the patients were male 92.3%, and the mean age was 28.3 ± 9.9 years. The gunshot mechanism of vascular injury was implicated in 76.1% of the injuries, and explosive-induced injury was 78 (23.9%). 193 (59.2%) of the patients had isolated arterial injuries, 117 (35.9%) patients had combined arterial and venous injuries while 18 (4.9%) patients had isolated venous injuries. The most commonly injured arteries were the femoral artery, followed by Brachial and popliteal artery injuries (26.1%, 23.5% and 19.4%, respectively). The median time to revascularization was 8.8 ± 8.7 h. 46.8% of the patients had Concomitant fractures, while 26.5% had Concomitant nerve injuries. Only three patients had temporary non-heparin-bound shunts during their arrival. The most common surgical intervention in arterial injuries was reversed saphenous vein graft 46.1%. The mortality was 5.8% and 7.7% of the patients needed secondary amputation. The majority of wartime arterial injuries are a result of Blast and gunshot vascular injuries. Frequent need for autologous vein grafts should be considered to manage such injuries. Results are encouraging despite delays in intervention; therefore, all viable limbs should be revascularized, keeping in mind the long-term functionality of the limb.
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Affiliation(s)
- Abdinafic Mohamud Hussein
- Department of Cardiovascular Surgery, Mogadishu Somalia Turkey Recep Tayyip Erdoğan Training and Research Hospital, Mogadishu, Somalia.
- Department of General Surgery, Benadir University, Mogadishu, Somalia.
| | - Abdijalil Abdullahi Ali
- Department of Cardiovascular Surgery, Mogadishu Somalia Turkey Recep Tayyip Erdoğan Training and Research Hospital, Mogadishu, Somalia
| | - Said Abdirahman Ahmed
- Department of Cardiology, Mogadishu Somalia Turkey Recep Tayyip Erdoğan Training and Research Hospital, Mogadishu, Somalia
| | - Mohamed Farah Yusuf Mohamud
- Department of Emergency Medicine, Mogadishu Somalia Turkey Recep Tayyip Erdoğan Training and Research Hospital, Mogadishu, Somalia
| | - Mohammed A M Ahmed
- Department of Pediatrics, Faculty of Medicine and Surgery, Mogadishu University, Mogadishu, Somalia
| | - Mehmet Kizilay
- Department of Cardiovascular Surgery, Mogadishu Somalia Turkey Recep Tayyip Erdoğan Training and Research Hospital, Mogadishu, Somalia
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Torres IO, Lourenço de Andrade RC, Apoloni R, Simão da Silva E, Puech-Leão P, De Luccia N. Editor's Choice - In Hospital and Long Term Outcomes After Repair of Subclavian and Axillary Artery Injuries. Eur J Vasc Endovasc Surg 2023; 66:840-847. [PMID: 37567338 DOI: 10.1016/j.ejvs.2023.08.008] [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: 01/26/2023] [Revised: 07/21/2023] [Accepted: 08/04/2023] [Indexed: 08/13/2023]
Abstract
OBJECTIVE To evaluate the in hospital and long term outcomes after open or endovascular repair of subclavian and axillary artery injuries. METHODS This was a retrospective, single centre study. Data were reviewed from patients with subclavian and or axillary injuries who presented to the authors' centre between January 2009 and December 2022. Outcome data included complications, death, amputations, and re-interventions. A p value < .050 was considered to be statistically significant. RESULTS Over the study period, 62 patients with subclavian or axillary trauma were admitted to the study hospital. Patients were young (median age 32.5 years, range 12 - 53) and most were men (85%); 32 patients experienced blunt trauma, and 30 penetrating trauma. The median injury severity score was 18 (interquartile range [IQR] 9, 34), and 47% of patients had a brachial plexus injury. The arterial injury was occlusion in 62% of patients, and the median ischaemia time was 12.5 hours (IQR 7.13, 24). All patients with subclavian injuries (n = 37) and 13 of 25 patients with an axillary injury underwent endovascular repair (stent graft placement). Open repair was performed in 12 patients with axillary injury (axillobrachial bypass in seven patients). At hospital discharge, the amputation free survival rate was 82% vs. 92% (p = .67), the mortality rate was 10% vs. 8% (p = 1.0), and the amputation rate was 10% vs. 0 (p = .57) for endovascular and open repair, respectively. The mean follow up time was 4.1 ± 3.5 years. After the seven year follow up, the stent primary patency was 42%. No re-interventions or amputations were performed after hospital discharge. Disability was related to fractures and soft tissue and brachial plexus injuries. CONCLUSION Endovascular treatment was preferred for patients with subclavian artery injuries. Open repair was preferred for patients with penetrating axillary injuries. In hospital and long term complications were related to fractures and soft tissue and brachial plexus injuries, rather than the treatment of arterial injuries. Measures are needed to reduce ischaemia time and improve brachial plexus injury repair.
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Affiliation(s)
- Inez Ohashi Torres
- Vascular and Endovascular Surgery Department, São Paulo University Medical School, São Paulo, Brazil.
| | | | - Rafael Apoloni
- Vascular and Endovascular Surgery Department, São Paulo University Medical School, São Paulo, Brazil
| | - Erasmo Simão da Silva
- Vascular and Endovascular Surgery Department, São Paulo University Medical School, São Paulo, Brazil
| | - Pedro Puech-Leão
- Vascular and Endovascular Surgery Department, São Paulo University Medical School, São Paulo, Brazil
| | - Nelson De Luccia
- Vascular and Endovascular Surgery Department, São Paulo University Medical School, São Paulo, Brazil
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Gallagher S, Sozzi M, Gallegos H, Ugarte C, Park S, Schellenberg M, Matsushima K, Magee GA, Inaba K, Martin M. Epidemiology and outcomes of traumatic vascular injury repair by trauma surgeons and vascular surgeons in a collaborative model. J Trauma Acute Care Surg 2023; 95:628-634. [PMID: 37012627 DOI: 10.1097/ta.0000000000003975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
BACKGROUND Management roles for peripheral vascular injuries (PVI) are a source of ongoing debate given the concern for the loss of vascular skills among general surgeons and trauma surgeons (TS). We sought to analyze outcomes of PVI managed by TSs or vascular surgeons (VSs). METHODS This is a retrospective study of a single, Level I trauma center. Trauma patients with PVI who underwent repair from 2010 to 2021 were included. Patients were separated into groups by the surgical specialty (TS or VS) undertaking the first intervention of the injured vessel. RESULTS A total of 194 patients were included, with 101 (52%) PVI managed by TS and 93 (48%) by VS. The TS group had more penetrating injuries (84% vs. 63%, p < 0.01), were more often hypotensive (17% vs. 6%, p = 0.01), and had a higher median Injury Severity Score (10 vs. 9, p < 0.001). Time from arrival to operating room was lower in the TS group (77 vs. 257 minutes, p < 0.01), with no difference in rates of preoperative imaging. The TS group performed damage-control surgery (DCS) more frequently (21% vs. 1.1%, p < 0.01). There was no difference in reintervention rates between the two groups after excluding patients that required reintervention for definitive repair after DCS (13% vs. 9%, p = 0.34). Mortality was 8% in the TS group and 1% in the VS group ( p = 0.02) with no deaths related to the PVI repair in either group. There was no difference in PVI repair complication rates between the two groups (18% vs. 13%; p = 0.36). CONCLUSION In our collaborative model at a high-volume trauma center, a wide variety of PVI are surgically managed by TS with VS. immediately available for consultation or for definitive repair of more complex vascular injuries. Trauma surgeons performed more DCS on higher acuity patients. No difference in vascular-related complications was detected between groups. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
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Affiliation(s)
- Shea Gallagher
- From the Division of Trauma and Acute Care Surgery, Department of Surgery (S.G., M.S., H.G., C.U., S.P., M.S., K.M., K.I., M.M.), and Division of Vascular Surgery, Department of Surgery (G.A.M.), LAC+USC Medical Center, Los Angeles, California
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Osofsky R, Hanif H, Massie P, Ramey S, Miskimins R, Clark R, Rana MA, Guliani S. Vascular Surgery Role in Vascular Trauma: 11-Year Analysis of Peripheral Vascular Trauma Management at a Level-1 Trauma Center. Ann Vasc Surg 2023:S0890-5096(23)00101-2. [PMID: 36805425 DOI: 10.1016/j.avsg.2023.01.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 01/04/2023] [Accepted: 01/26/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND Vascular surgeons are increasingly relied upon in the management of complex peripheral vascular trauma. The degree however that vascular surgery (VS) is involved in vascular trauma care is not well established. We hypothesize that VS consultation is required in a high portion of complex lower extremity vascular trauma. METHODS A single-center retrospective review of all consecutive patients who sustained traumatic arterial injury of the lower extremity requiring open operative repair at a level-1 trauma center (from February 2009 to May 2020) was performed. Patients who underwent surgical repair were stratified by the service that performed the operation (VS versus trauma surgery [TS]). Secondary outcomes assessed included location of arterial injury, type of repair, and clinical outcomes. RESULTS A total of 111 patients underwent operative repair of lower extremity arterial injury (mean age 34.5 ± 15.5 years, 89% male). The most common vessels requiring intervention were the superficial femoral artery (n = 42, 38%), popliteal artery (n = 35, 31.5%), and tibial vessels (n = 19, 17.1%). The most common intervention required in patients was an autologous bypass (n = 85, 76.5%), followed by ligation (n = 9, 8.1%) and primary repair (n = 6, 5.4%). Most interventions overall required VS involvement (n = 95, 86%). VS performed a higher proportion of autologous graft procedures compared to TS (n = 79, 92.9% vs. n = 6, 7.1%). VS case load overall was likewise predominantly autologous grafts (n = 79/95, 83.2%). TS operated on a higher proportion of injuries to the tibial vessels (44% vs. 13%, P = 0.01), whereas VS intervened more frequently on popliteal injuries (36% vs. 6%, P = 0.02). With regard to the method of arterial repair, TS was more likely to perform ligation (38% vs. 3 %, P < 0.001) or primary repair (13% vs. 3%, P = 0.04) compared to VS. However, VS was more likely to perform repair with autologous graft (83% vs. 38%, P < 0.001). There were no significant differences in rates of mortality, limb loss, transfusions requirement, fasciotomy, deep venous thrombosis, hematoma formation, or length of stay between groups. Although, surgical site infections were more common in the TS group (38% vs. 15%, P = 0.04). CONCLUSIONS Vascular surgeons play a large role in managing complex lower extremity vascular trauma. In particular, VS remains integral for the management of more difficult injuries (e.g., popliteal injuries) and is more likely to provide more complex repairs (e.g., autologous grafts).
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Affiliation(s)
- Robin Osofsky
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM
| | - Hamza Hanif
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM.
| | - Pierce Massie
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM
| | - Shannen Ramey
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM
| | - Richard Miskimins
- Division of Acute Care Surgery, University of New Mexico School of Medicine, Albuquerque, NM
| | - Ross Clark
- Division of Vascular Surgery, University of New Mexico School of Medicine, Albuquerque, NM
| | - Muhammad Ali Rana
- Division of Vascular Surgery, University of New Mexico School of Medicine, Albuquerque, NM
| | - Sundeep Guliani
- Division of Acute Care Surgery, University of New Mexico School of Medicine, Albuquerque, NM; Division of Vascular Surgery, University of New Mexico School of Medicine, Albuquerque, NM
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Karam BS, Haberman K, Nguyen P, Eddine SBZ, Boyle K, Baskaran A, Figueroa J, Milia D, Carver T, Somberg L, Webb T, Davis CS, Dodgion C, Elegbede A, de Moya MA. Trauma surgeon-performed peripheral arterial repairs are associated with equivalent outcomes when compared with vascular surgeons. J Trauma Acute Care Surg 2022; 92:754-759. [PMID: 35001022 DOI: 10.1097/ta.0000000000003531] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Civilian extremity trauma with vascular injury carries a significant risk of morbidity, limb loss, and mortality. We aim to describe the trends in extremity vascular injury repair and compare outcomes between trauma and vascular surgeons. METHODS We performed a single-center retrospective review of patients 18 years or older with extremity vascular injury requiring surgical intervention between January 2009 and December 2019. Demographics, injury characteristics, operative course, and hospital course were analyzed. Descriptive statistics were used to examine management trends, and outcomes were compared for arterial repairs. Multivariate regression was used to evaluate surgeon specialty as a predictor of complications, readmission, vascular outcomes, and mortality. RESULTS A total of 231 patients met our inclusion criteria; 80% were male with a median age of 29 years. The femoral vessels were most commonly injured (39.4%), followed by the popliteal vessels (26.8%). Trauma surgeons performed the majority of femoral artery repairs (82%), while vascular surgeons repaired the majority of popliteal artery injuries (84%). Both had a similar share of brachial artery repairs (36% vs. 39%, respectively). There were no differences in complications, readmission, vascular outcomes, and mortality. Median time from arrival to operating room was significantly shorter for trauma surgeons. There was a significant downward trend between 2009 and 2017 in the proportion of total and femoral vascular procedures performed by trauma surgeons. On multivariate regression, surgical specialty was not a significant predictor of need for vascular reintervention, prophylactic or delayed fasciotomies, postoperative complications, or readmissions. CONCLUSION Traumas surgeons arrived quicker to the operating and had no difference in short-term clinical outcomes of brachial and femoral artery repairs compared with patients treated by vascular surgeons. Over the last decade, there has been a significant decline in the number of open vascular repairs done by trauma surgeons. LEVEL OF EVIDENCE Therapeutic/Care Management, Level IV.
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Affiliation(s)
- Basil S Karam
- From the Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
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7
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Stonko DP, Betzold RD, Abdou H, Edwards J, Azar FK, Elansary NN, Treffalls RN, Savidge SG, DuBose JJ, Feliciano DV, Morrison JJ. In-hospital outcomes in autogenous vein versus synthetic graft interposition for traumatic arterial injury: A propensity-matched cohort from PROOVIT. J Trauma Acute Care Surg 2022; 92:407-412. [PMID: 34789705 DOI: 10.1097/ta.0000000000003465] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The ideal conduit for traumatic arterial repair is controversial. Autologous vein was compared with synthetic interposition grafts in the acute setting. The primary outcome was in-hospital reoperation or endovascular intervention. METHODS The American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment registry from November 2013 to January 2019 was queried for arterial injuries requiring interposition vein or graft repair. Patients with no recorded Injury Severity Score were excluded, and multiple imputation was used for other missing data. Patients treated with synthetic grafts (SGs) were propensity matched to patients with vein grafts (VGs) to account for preoperative differences. RESULTS Four hundred sixty from 19 institutions were identified, with 402 undergoing VG and 58 SG. In the SG group, 45 were PTFE grafts, 5 were Dacron, and 8 had other conduits. The SG group was more severely injured at admission with more gunshot wounds and higher mean Injury Severity Score, lactate, and first-24-hour transfusion requirement. In addition, the SG cohort had significantly lower admission systolic blood pressure, pH, and hemoglobin. After propensity matching, 51 patients with SG were matched with 87 patients with VG. There were no differences in demographics, clinical parameters, or diagnostic evaluation techniques postmatch. The need for reoperation or endovascular intervention between the matched groups was equivalent (18%; p = 0.8). There was no difference in any secondary outcome including thrombosis, stenosis, pseudoaneurysm, infection, or embolic event, and hospital and intensive care unit length of stay were the same. CONCLUSION American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment registry data demonstrate that SGs are used in more critically ill patients. After controlling for relevant clinical factors and propensity matching, there is no in-hospital difference in rate of reoperation or endovascular intervention, or any secondary outcome between VG and SG. LEVEL OF EVIDENCE Prognostic and Epidemiolgic, Level III.
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Affiliation(s)
- David P Stonko
- From the Department of Surgery (D.P.S.), The Johns Hopkins Hospital; Department of Surgery, University of Maryland (D.P.S., R.D.B., H.A., J.E., N.N.E., R.N.T., S.G.S., J.J.D., D.V.F., J.J.M.), R. Adams Cowley Shock Trauma Center, Baltimore, Maryland; and Department of Surgery, St. Mary's Medical Center (F.K.A.), West Palm Beach; Florida Atlantic University (F.K.A.), Boca Raton, Florida; and University of Maryland School of Medicine (S.G.S.), Baltimore, Maryland
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8
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Choi K, Keum MA, Kim MS, Kim Y, Choi S, Kyoung KH, Kim JT, Kim S, Noh M. Feasibility of the Ultrasound-Guided Insertion of the Peripherally Inserted Central Catheter (PICC) by the Vascular Surgeon at the Bedside in the Trauma Intensive Care Unit. Ann Vasc Surg 2021; 80:143-151. [PMID: 34688877 DOI: 10.1016/j.avsg.2021.08.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 08/06/2021] [Accepted: 08/09/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND This study analyzed the outcomes of the ultrasound-guided insertion of the peripherally inserted central venous catheter (PICC) by experienced vascular surgeons at the bedside of the trauma intensive care unit (ICU) and compared the outcomes with those of fluoroscopy-guided PICC performed by radiologists in the interventional suite. METHODS Between May 1, 2016, and April 30, 2021, 97 patients who were hospitalized in the trauma ICU and underwent PICC insertion were enrolled in the study. Forty-two out of the 97 patients underwent PICC insertion by interventional radiologists in the interventional radiology suite under fluoroscopy guidance, while the remaining 55 cases underwent ultrasound-guided PICC insertion by the vascular surgeon at the trauma ICU bedside. RESULTS The technical failure (P = 0.504) and malposition (P = 0.127) rates were not significantly different between the 2 groups. However, it took significantly less time for the vascular surgeon to complete the PICC insertion procedure (P < 0.001). Significantly more patients of the ultrasound-guided group required inotropes (P = 0.012) and mechanical ventilation (P = 0.003) at the time of the procedure. In addition, the ultrasound-guided group appeared to be in critical condition in terms of kidney function according to laboratory data (P = 0.014). Meanwhile, the ultrasound-guided group maintained the central line catheter for a shorter time (P < 0.001). CONCLUSIONS In trauma patients, ultrasound-guided PICC insertion at the bedside by experienced vascular surgeons at the trauma ICU was feasible compared to fluoroscopy-guided insertion performed by interventional radiologists.
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Affiliation(s)
- Kyunghak Choi
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Min Ae Keum
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Min Soo Kim
- Department of Neurosurgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Youngwoong Kim
- Department of Thoracic and Cardiovascular Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Seongho Choi
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Kyu-Hyouck Kyoung
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Jihoon T Kim
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Sungjeep Kim
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Minsu Noh
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea.
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9
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Comment on: Beyond the Crossroads by DuBose et al. Ann Surg 2020; 274:e863-e864. [PMID: 33630472 DOI: 10.1097/sla.0000000000004664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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10
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Masood A, Danawar NA, Mekaiel A, Raut S, Malik BH. The Utility of Therapeutic Anticoagulation in the Perioperative Period in Patients Presenting in Emergency Surgical Department With Extremity Vascular Injuries. Cureus 2020; 12:e8473. [PMID: 32642377 PMCID: PMC7336685 DOI: 10.7759/cureus.8473] [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: 11/27/2022] Open
Abstract
Extremity vascular trauma is a challenging surgical emergency in both civilian population and combat environment. It requires vigilant diagnosis and prompt treatment to minimize limb loss and mortality. A multidisciplinary team approach is required to deal with shock states, concomitant abdominal injuries, head injuries, and fractures with significant tissue loss and psychological stress. Anticoagulation is frequently used during traumatic vascular repair to avoid repair site thrombosis, postoperative deep venous thrombosis, and pulmonary embolism (PE). In this review article, we are going to search about how frequent is the use of anticoagulation in terms of limb salvage rates, and mortality rates or side effects of anticoagulation in terms of risk of bleeding episodes, and the need for future prospective studies. Extremity vascular trauma is managed by a variety of methods including open repairs, endovascular repairs, and nonoperative management. Most of the literature demonstrates the use of systemic or regional anticoagulation in the management of vascular injuries with the improvement in limb salvage rates and reduced morbidities but confounding factors lead to variable results. Some studies show an increased risk of bleeding in trauma patients with the use of anticoagulants in trauma settings without any significant effect on repair site thrombosis. More comprehensive studies and randomized controlled trials are needed to confirm the importance of perioperative anticoagulation while avoiding the confounding factors in terms of injury severity scores, ischemia time, demographics of patients, modes of injury, comorbidities, grades of shock, concomitant injuries that need anticoagulation like venous injuries or intracranial injuries that are contraindications to the use of anticoagulation, type of anticoagulation and expertise available as well as the experience level of the operating surgeon. Literature also reveals the use of new oral anticoagulants (e.g., dabigatran) to be associated with lesser bleeding episodes when compared to warfarin, so in future, we can check the feasibility of these agents to reduce the bleeding episodes and at the same time improve the limb salvage rates.
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Affiliation(s)
- Ayesha Masood
- General Surgery, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Nuaman A Danawar
- General Surgery, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Andrew Mekaiel
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Sumit Raut
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Bilal Haider Malik
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
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Parihar S, Benarroch-Gampel J, Teodorescu V, Ramos C, Minton K, Rajani RR. Vascular Surgeons Carry an Increasing Responsibility in the Management of Lower Extremity Vascular Trauma. Ann Vasc Surg 2020; 70:87-94. [PMID: 32422294 DOI: 10.1016/j.avsg.2020.05.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 04/21/2020] [Accepted: 05/02/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND There is preliminary evidence that vascular surgeons are increasingly relied on nationally to assist with the management of lower extremity vascular trauma. Current trauma center verification, however, does not require any level of vascular surgery coverage. We sought to assess practice patterns regarding vascular surgery consultation and temporal trends in the surgical management of these patients. METHODS A retrospective analysis was performed on all patients who underwent surgical repair for vascular trauma of the lower extremity at a single, academic, public hospital from 2011 to 2018. Demographic data and procedural data were collected. Patients were assigned to a vascular surgery (VS) or nonvascular surgery (NV) group. The primary outcome measure was the rate of VS consultation. Secondary outcome measures included 30-day mortality, length-of-stay, and limb salvage. RESULTS One hundred eighty patients were identified (77 VS group, 103 NV group). There was an increase in the proportion of repairs done by VS from 2011 to 2018 (P < 0.05). There were significant management differences between the 2 groups, with vascular surgeons more likely to perform primary end-to-end anastomosis for both arterial (21.33% vs. 6.90%) and venous (19.15% vs. 5.26%) injuries (both P < 0.05). Patients in the VS group were less likely to have balloon embolectomy, fasciotomy, or intravascular shunting than the NV group (all P < 0.05). There were no significant differences in mortality (5.35% vs. 4.85%), length-of-stay (15.05 vs. 18.38 days), or limb salvage (94.81% vs. 95.15%). CONCLUSIONS Lower extremity vascular trauma is increasingly managed by vascular surgeons. Furthermore, vascular surgeons are more selective in the use of potentially unnecessary adjunctive maneuvers. Current accreditation guidelines should be revisited to mandate vascular surgery coverage in trauma centers that frequently treat this patient population.
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Affiliation(s)
- Sid Parihar
- Division of Vascular and Endovascular Surgery, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA
| | - Jaime Benarroch-Gampel
- Division of Vascular and Endovascular Surgery, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA
| | - Victoria Teodorescu
- Division of Vascular and Endovascular Surgery, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA
| | - Christopher Ramos
- Division of Vascular and Endovascular Surgery, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA
| | - Keri Minton
- Division of Vascular and Endovascular Surgery, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA
| | - Ravi R Rajani
- Division of Vascular and Endovascular Surgery, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA.
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Kauvar DS, Propper BW, Arthurs ZM, Causey MW, Walters TJ. Impact of Staged Vascular Management on Limb Outcomes in Wartime Femoropopliteal Arterial Injury. Ann Vasc Surg 2020; 62:119-127. [DOI: 10.1016/j.avsg.2019.08.072] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 07/17/2019] [Accepted: 08/22/2019] [Indexed: 10/26/2022]
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13
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Assessment of the "Weekend Effect" in Lower Extremity Vascular Trauma. Ann Vasc Surg 2019; 66:233-241.e4. [PMID: 31863955 DOI: 10.1016/j.avsg.2019.11.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 11/24/2019] [Accepted: 11/26/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Studies suggest that patients admitted on weekends may have worse outcomes as compared with those admitted on weekdays. Lower extremity vascular trauma (LEVT) often requires emergent surgical intervention and might be particularly sensitive to this "weekend effect." The objective of this study was to determine if a weekend effect exists for LEVT. METHODS The National and Nationwide Inpatient Sample Database (2005-2014) was queried to identify all adult patients who were admitted with an LEVT diagnosis. Patient and hospital characteristics were recorded or calculated and outcomes including in-hospital mortality, amputation, length of stay (LOS), and discharge disposition were assessed. Independent predictors of outcomes were identified using multivariable regression models. RESULTS There were 9,282 patients admitted with LEVT (2,866 weekend admissions vs. 6,416 weekday admissions). Patients admitted on weekends were likely to be younger than 45 years (68% weekend vs. 55% weekday, P < 0.001), male (81% weekend vs. 75% weekday, P < 0.001), and uninsured (22% weekend vs. 17% weekday, P < 0.001) as compared with patients admitted on weekdays. There were no statistically significant differences in mortality (3.8% weekend vs. 3.3% weekday, P = 0.209), amputation (7.2% weekend vs. 6.6% weekday, P = 0.258), or discharge home (57.4% weekend vs. 56.1% weekday, P = 0.271). There was no clinically significant difference in LOS (median 7 days weekend vs. 7 days weekday), P = 0.009. On multivariable regression analyses, there were no statistically significant outcome differences between the groups. CONCLUSIONS This study did not identify a weekend effect in LEVT patients in the United States. This suggests that factors other than the day of admission may be important in influencing outcomes after LEVT.
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Dhillan R, Bhalla A, Jha SK, Singh H, Arora A. Vascular Injuries Due to Penetrating Missile Trauma in Anti-Terrorism Ops. JOURNAL OF TRAUMA AND INJURY 2019. [DOI: 10.20408/jti.2018.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Rishi Dhillan
- Department of Surgery, Base Hospital, Srinagar, India
| | - Alok Bhalla
- Department of Surgery, Base Hospital, Srinagar, India
| | | | - Hakam Singh
- Department of Surgery, Base Hospital, Srinagar, India
| | - Aman Arora
- Department of Surgery, Base Hospital, Srinagar, India
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Aizpuru M, Sweeney AP, Watson JD, Harris DG, Drucker CB, Diaz JJ, Crawford RS. Vascular Acute Care Surgery (VACS) Services: A New Model for the Future and a Solution to the Emerging Vascular Surgery Coverage Crisis. CURRENT SURGERY REPORTS 2019. [DOI: 10.1007/s40137-019-0236-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Reyna-Sepúlveda F, Hernández-Guedea M, Rodríguez-García J, Martínez-Fernández A, Rodríguez-Briseño J, Muñoz-Maldonado G. Epidemiología y evolución perioperatoria de lesión vascular periférica en civiles por trauma penetrante durante una década. ANGIOLOGIA 2017. [DOI: 10.1016/j.angio.2017.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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