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Izawa Y, Futamura K, Murakami H, Sato K, Tsuchida Y. Efficacy of Orthoplastic Management in the Treatment of Traumatic Popliteal Artery Injury. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5696. [PMID: 38528846 PMCID: PMC10962880 DOI: 10.1097/gox.0000000000005696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 02/06/2024] [Indexed: 03/27/2024]
Abstract
Background Popliteal artery injury (PAI) is a challenging condition. Even with appropriate initial treatment and reconstruction of the associated injuries, extensive soft-tissue necrosis may occur, requiring lower leg amputation. There are no reports on the effectiveness of orthoplastic surgery in treating traumatic PAI. However, orthoplastic surgery is also considered very effective in PAI treatment, which requires delicate handling of soft-tissue and blood vessels. This study aimed to examine the treatment outcomes of traumatic PAI at a trauma center with the capacity for orthoplastic management. Methods Patients with PAI who were treated at our institution between August 2013 and December 2021 were included in this study. The surgeons included multiple orthoplastic surgeons with capabilities in vascular repair, bone and ligament reconstruction, and soft-tissue reconstruction. Patient demographics, injury characteristics, degree of ischemia, and treatment were investigated. We also investigated whether soft-tissue reconstruction and lower limb amputation were necessary as outcomes of treatment. Results Fifteen limbs of 14 patients with PAI met the inclusion criteria. Extensive soft-tissue necrosis was observed in three limbs. Two of these limbs were covered with a free latissimus dorsi flap and could be salvaged. In the remaining limb, lower limb amputation was unavoidable because of unexplained cardiac arrest during the initial surgery, but a fillet flap was used to successfully preserve the knee joint. Conclusion Orthoplastic management has the potential to improve limb salvage rates and provide good outcomes for the treatment of traumatic PAI.
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Affiliation(s)
- Yuta Izawa
- From the Department of Orthopaedic Trauma Center, Sapporo Higashi Tokushukai Hospital, Hokkaido, Japan
- Department of Trauma Center, Shonan Kamakura General Hospital, Kanagawa, Japan
| | - Kentaro Futamura
- Department of Trauma Center, Shonan Kamakura General Hospital, Kanagawa, Japan
| | - Hiroko Murakami
- From the Department of Orthopaedic Trauma Center, Sapporo Higashi Tokushukai Hospital, Hokkaido, Japan
| | - Kazuo Sato
- From the Department of Orthopaedic Trauma Center, Sapporo Higashi Tokushukai Hospital, Hokkaido, Japan
| | - Yoshihiko Tsuchida
- Department of Trauma Center, Shonan Kamakura General Hospital, Kanagawa, Japan
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Izawa Y, Futamura K, Murakami H, Shirakawa T, Nishida M, Suzuki T, Tsuchida Y. Cross-Limb Vascular Shunting for Traumatic Popliteal Artery Injury. Ann Vasc Surg 2024; 99:305-311. [PMID: 37858669 DOI: 10.1016/j.avsg.2023.08.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/10/2023] [Accepted: 08/20/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Popliteal artery injury (PAI) is a challenging trauma that requires prompt and accurate treatment since the probability of lower-limb amputation increases with the ischemic time. Intravascular shunting and cross-limb vascular shunting (CLS) are used as temporary vascular shunting (TVS) methods to shorten the ischemic time for limb vascular injury. CLS involves sending blood from an artery in a healthy body part to a peripheral vessel in an injured part to immediately resume blood flow to the injured limb. For closed injuries including PAI, CLS may be performed without exploring and identifying the arterial stumps and it enables early reperfusion to the ischemic limb. We report the case series of traumatic PAI treated using CLS and verify the usefulness of CLS. METHODS All patients with traumatic PAI treated with CLS at our institution between August 2013 and December 2021 were included. Demographic and clinical patient characteristics were extracted from the medical records. Comorbid injuries, severity of acute limb ischemia based on the Rutherford grading scale, time from injury to reperfusion by CLS, time from injury to completion of artery, and the use of fasciotomy were investigated. As outcomes, we investigated the presence or absence of lower extremity amputation during the course of treatment. RESULTS We used CLS as treatment for 5 cases with traumatic PAI. Based on the Rutherford grading scale for acute limb ischemia, there were one limb with grade 2B and 4 with grade 3. Amputation of the lower extremities was avoided except for 1 extremity in which arterial reconstruction was not achieved due to unexplained cardiac arrest during surgery. CONCLUSIONS CLS enables early reperfusion of the injured limb and is effective as a TVS method for traumatic PAI with severe ischemia or soft tissue damage.
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Affiliation(s)
- Yuta Izawa
- Department of Orthopaedic Trauma Center, Sapporo Higashi Tokushukai Hospital, Sapporo, Hokkaido, Japan.
| | - Kentaro Futamura
- Department of Trauma Center, Shonan Kamakura General Hospital, Kamakura, Kanagawa, Japan
| | - Hiroko Murakami
- Department of Orthopaedic Trauma Center, Sapporo Higashi Tokushukai Hospital, Sapporo, Hokkaido, Japan
| | - Tetsuya Shirakawa
- Department of Orthopaedic Trauma Center, Sapporo Higashi Tokushukai Hospital, Sapporo, Hokkaido, Japan
| | - Masahiro Nishida
- Department of Trauma Center, Shonan Kamakura General Hospital, Kamakura, Kanagawa, Japan
| | - Takafumi Suzuki
- Department of Trauma Center, Shonan Kamakura General Hospital, Kamakura, Kanagawa, Japan
| | - Yoshihiko Tsuchida
- Department of Trauma Center, Shonan Kamakura General Hospital, Kamakura, Kanagawa, Japan
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3
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Izawa Y, Sato K, Tsuchida Y. Traumatic popliteal artery spasm diagnosed using intraoperative angiography: A case report. Trauma Case Rep 2023; 46:100863. [PMID: 37347007 PMCID: PMC10279907 DOI: 10.1016/j.tcr.2023.100863] [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] [Accepted: 06/03/2023] [Indexed: 06/23/2023] Open
Abstract
There are few reports of traumatic arterial spasm in large-sized vessels in the extremities, and many surgeons are skeptical of its existence. We report a case of traumatic popliteal artery injury (PAI), which was later diagnosed as traumatic popliteal artery spasm on intraoperative angiography. A male patient, aged 54 years, was injured when a heavy object weighing approximately 100 kg fell on his right knee. Three hours after the injury, the patient was transported to our trauma center. The dorsalis pedis and posterior tibial arteries were not palpable, and his right lower leg was cold. However, he could move his ankle and toes completely and had no numbness or paresthesia in his right lower limb. Computed tomography angiography showed an interruption of the popliteal artery at the knee joint level and an enhancement on the distal side of the injury site. We diagnosed lower limb ischemia resulting from PAI and operated for revascularization. Under general anesthesia, the popliteal artery was explored via a posterior S-shaped incision in the prone position. No arterial abnormalities were observed macroscopically, and the injured area remained unidentified. Therefore, a contrast medium was injected into the popliteal artery using a 20-gauge intravascular needle, and angiography was performed, which revealed that the popliteal artery was patent; however, there was circumferential arterial stenosis at the level of the knee joint. At this point, the right lower limb's coldness had disappeared. Arterial spasm was speculated to cause the transient popliteal occlusion and lower leg ischemia. Immediate revascularization should be attempted when PAI is suspected. If no gross vascular abnormalities are confirmed, intraoperative angiography is useful for diagnosing arterial spasm.
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Affiliation(s)
- Yuta Izawa
- Corresponding author at: Department of Orthopaedic Trauma Center, Kita 33 Jou Higashi 14 chome 3-1, Higashiku, Sapporo, Hokkaido, Japan.
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Barnard L, Karimian S, Foster P, Shankar VK. Blunt Vascular Trauma in the Lower Extremity at a Major Trauma Centre: Salvage Rate and Complications. Strategies Trauma Limb Reconstr 2023; 18:87-93. [PMID: 37942434 PMCID: PMC10628618 DOI: 10.5005/jp-journals-10080-1588] [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: 03/03/2022] [Accepted: 01/23/2023] [Indexed: 11/10/2023] Open
Abstract
Introduction Blunt trauma of the lower limb with vascular injury can cause devastating outcomes, including loss of limb and even loss of life. The primary aim of this study was to determine the limb salvage rate of patients sustaining such injuries when treated at Leeds General Infirmary (LGI) since becoming a Major Trauma Centre (MTC). The secondary aim was to establish patient complications. Methods A retrospective analysis found that from 2013 to 2018, 30 patients, comprising of 32 injured limbs, were treated for blunt trauma to the lower limb associated with vascular injury. Results Twenty-four patients were male and six were female. Their mean ages were 32 and 49, respectively. Three limbs were deemed unsalvageable and underwent primary amputation; of the remaining 29 potentially salvageable limbs, 27 (93%) were saved. Median ischaemic times for both amputees and salvaged limbs were under 6 hours. Of the 32 limbs, 27 (84%) were salvaged. All amputees had a MESS score ≥ 7, although not all patients with MESS ≥ 7 required amputation. Eleven limbs had prophylactic fasciotomies, three limbs developed compartment syndrome - all successfully treated and three contracted deep infections - one of which necessitated amputation. All but one patient survived their injuries and were discharged from the hospital. Conclusion Attempted salvage of 27/29 (93%) limbs was successful and all but one patient survived these injuries when treated at an MTC. MESS scoring and ischaemic time are useful but not sole predictors of limb salvage. Complication rates are low but may be significant for their future implications. How to cite this article Barnard L, Karimian S, Foster P, et al. Blunt Vascular Trauma in the Lower Extremity at a Major Trauma Centre: Salvage Rate and Complications. Strategies Trauma Limb Reconstr 2023;18(2):87-93.
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Affiliation(s)
- Liam Barnard
- Leeds School of Medicine, Worsley Building, University of Leeds, Woodhouse, Leeds, United Kingdom
| | - Sina Karimian
- Leeds School of Medicine, Worsley Building, University of Leeds, Woodhouse, Leeds, United Kingdom
| | - Patrick Foster
- Department of Trauma and Orthopaedics, Leeds Vascular Institute, Leeds General Infirmary, Leeds, United Kingdom
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Davidovic LB, Koncar IB, Dragas MV, Markovic MD, Bogavac-Stanojevic N, Vujcic AD, Mitrovic AC, Ilic NS, Trailovic RD, Kostic DM. Treatment of vascular non-iatrogenic injuries of upper and lower extremities in tertiary vascular center. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:74-81. [PMID: 36168950 DOI: 10.23736/s0021-9509.22.12243-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The purpose of this study was to examine demographic and baseline characteristics of patients with vascular injuries of extremities and to define the most relevant factors which influenced an early outcome, as well as limb salvage after the management of vascular trauma. METHODS This study used the database that included 395 patients with peripheral arterial injuries, who were treated in the tertiary vascular university center in the period between 2005-2020. Exclusion criteria were isolated thoracic, abdominal and neck injuries as well as iatrogenic injuries and injuries of intravenous addicts. Univariate binary logistic regression analysis and multiple logistic regression were used to determine risk factors for lomb loss (after vascular reconstruction) or mortality. Decision to perform primary amputation (without vascular reconstruction) was based on surgeons' preference and experience. RESULTS Out of 395 vascular injuries treated in the period 2005-2020, 210 (53.2%) presented with non-iatrogenic vascular injuries of upper and lower extremities were analyzed. According to the univariate regression analysis, hemorrhage as the main clinical manifestation on admission (P=0.035) and early reintervention (P=0.048) increased, while an early patency of repaired artery (0.010) significantly decreased a 30-day amputation rate. Multivariate logistic regression analysis of these three variables showed that only early patency of repaired artery significantly decreased the early amputation rate (P=0.009). CONCLUSIONS Based on presented experience, the patency of vascular reconstruction plays a crucial role in limb salvage in patients with non-iatrogenic peripheral vascular injuries. All factors that might influence the patency should be in focus of improvement.
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Affiliation(s)
- Lazar B Davidovic
- Clinic for Vascular and Endovascular Surgery, University Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Igor B Koncar
- Clinic for Vascular and Endovascular Surgery, University Clinical Center of Serbia, Belgrade, Serbia - .,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marko V Dragas
- Clinic for Vascular and Endovascular Surgery, University Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Miroslav D Markovic
- Clinic for Vascular and Endovascular Surgery, University Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | | | - Aleksandra D Vujcic
- Clinic for Vascular and Endovascular Surgery, University Clinical Center of Serbia, Belgrade, Serbia
| | - Aleksandar C Mitrovic
- Clinic for Vascular and Endovascular Surgery, University Clinical Center of Serbia, Belgrade, Serbia
| | - Nikola S Ilic
- Clinic for Vascular and Endovascular Surgery, University Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ranko D Trailovic
- Clinic for Vascular and Endovascular Surgery, University Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Dusan M Kostic
- Clinic for Vascular and Endovascular Surgery, University Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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Deng P, Yang J, Hacquebord JH, Qin B, Wang H, Li P, Gu L, Qi J, Zhu Q. Degree of Soft Tissue Injury is a Major Determinant of Successful Arterial Repair in the Extremity: A New Classification of Extremity Arterial Injury? J INVEST SURG 2022; 35:1562-1570. [PMID: 35361053 DOI: 10.1080/08941939.2022.2055237] [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: 10/18/2022]
Abstract
BACKGROUND This study aimed to investigate outcomes after extremity arterial injury repair and examined the association between outcomes and the degree of soft tissue injury and vascular repair methods. METHODS A retrospective study was conducted on 106 patients (108 cases) who underwent emergent microsurgical repair of extremity arterial injury due to trauma and non-perfusion of the affected extremity. The cases were divided into three groups by degree of associated soft tissue injuries: (A) adequate soft tissue coverage over the injured major vessels after radical debridement, (B) inadequate soft tissue coverage over the injured major vessels after radical debridement, and (C) radical debridement was not feasible due to unclear extent of injured soft tissue. Differences in vascular repair methods and outcomes among the three groups were analyzed. RESULTS In Group A (n = 61), microvascular suture and vessel graft achieved 95.1% and 85.0% successful limb reperfusion, respectively. In Group B (n = 31), vessel reconstruction with flap coverage achieved 100% successful reperfusion. Vessel graft achieved 28.6% successful limb reperfusion, while there were no cases of successful reperfusion using microvascular sutures. In Group C (n = 16), no vascular repair method achieved successful reperfusion. There were significant differences among the three groups in successful reperfusion (p < 0.001) and limb salvage (p < 0.001). CONCLUSION The extent of associated soft tissue injury was associated with different vascular repair methods and outcomes. We propose a new system for classifying these injuries according to the degree of associated soft tissue injury.
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Affiliation(s)
- Peijun Deng
- Department of Microsurgery, Orthopaedic Trauma and Hand Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Orthopaedics and Traumatology, Guangzhou, China
| | - Jiantao Yang
- Department of Microsurgery, Orthopaedic Trauma and Hand Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Orthopaedics and Traumatology, Guangzhou, China
| | - Jacques Henri Hacquebord
- Department of Orthopedic Surgery and Hansjörg Wyss Department of Plastic Surgery, New York University School of Medicine, New York, USA
| | - Bengang Qin
- Department of Microsurgery, Orthopaedic Trauma and Hand Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Orthopaedics and Traumatology, Guangzhou, China
| | - Honggang Wang
- Department of Microsurgery, Orthopaedic Trauma and Hand Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Orthopaedics and Traumatology, Guangzhou, China
| | - Ping Li
- Department of Microsurgery, Orthopaedic Trauma and Hand Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Orthopaedics and Traumatology, Guangzhou, China
| | - Liqiang Gu
- Department of Microsurgery, Orthopaedic Trauma and Hand Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Orthopaedics and Traumatology, Guangzhou, China
| | - Jian Qi
- Department of Microsurgery, Orthopaedic Trauma and Hand Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Orthopaedics and Traumatology, Guangzhou, China
| | - Qingtang Zhu
- Department of Microsurgery, Orthopaedic Trauma and Hand Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Orthopaedics and Traumatology, Guangzhou, China
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Hussain SA, Walters S, Ahluwalia A, Trompeter A. Diagnosis and management of arterial injuries associated with limb fracture or dislocation. Br J Hosp Med (Lond) 2022; 83:1-8. [DOI: 10.12968/hmed.2021.0454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
An arterial injury is a time-critical emergency and, when associated with a fracture or dislocation, its management requires joint specialist input from orthopaedic and vascular or plastic surgeons. Initial management involves haemorrhage control and stabilisation of the patient, reduction and splinting of the limb and careful reassessment. With ongoing vascular compromise, urgent surgery is indicated to restore arterial flow and stabilise the skeleton, and this should be performed at a centre with appropriate expertise. This article provides an evidence-based review of the British Orthopaedic Association Standards for Trauma for the diagnosis and management of arterial injuries associated with extremity fractures and dislocations.
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Affiliation(s)
- SA Hussain
- Department of Trauma and Orthopaedic Surgery, Croydon University Hospital, London, UK
| | - S Walters
- Department of Trauma and Orthopaedic Surgery, Croydon University Hospital, London, UK
| | - A Ahluwalia
- Department of Trauma and Orthopaedic Surgery, University College Hospital, London, UK
| | - A Trompeter
- Orthopaedic Trauma/Limb Reconstruction Unit, St George's University Hospital, London, UK
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8
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Laverty RB, Treffalls RN, Kauvar DS. Systematic review of temporary intravascular shunt use in military and civilian extremity trauma. J Trauma Acute Care Surg 2022; 92:232-238. [PMID: 34538830 DOI: 10.1097/ta.0000000000003399] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The use of temporary intravascular shunts (TIVS) in the setting of military and civilian trauma has grown in recent years, predominantly because of the mounting evidence of improved limb outcomes. We sought to characterize the use and outcomes of TIVS in trauma through a systematic review of military and civilian literature. METHODS The MEDLINE, EBSCO, EMBASE, and Cochrane databases were searched for studies on TIVS use in military and civilian trauma settings published between January 2000 and March 2021. Reports lacking systematic data collection along with those with insufficient TIVS descriptive and outcome data were excluded. Data regarding the characteristics and outcomes of TIVS were assessed and collective syntheses of military and civilian data performed. RESULTS Twenty-one reports were included, 14 from civilian trauma centers or databases and 7 from military field data or databases (total of 1,380 shunts in 1,280 patients). Sixteen were retrospective cohort studies, and four were prospective. Five studies had an unshunted comparison group. Shunts were predominantly used in the lower extremity and most commonly for damage control indications. Dwell times were infrequently reported and were not consistently linked to shunt thrombosis or other complications. Anticoagulation during shunting was sparsely reported and inconsistently applied. Shunted limbs had higher injury severity than unshunted limbs but similar salvage rates. CONCLUSION Temporary intravascular shunts are effective for expeditious restoration of perfusion in severely injured limbs and likely contribute to limb salvage. There is a paucity of comparative TIVS data in the literature and no consistently applied reporting standards, so controversies regarding TIVS use remain. LEVEL OF EVIDENCE Systematic Review, level IV.
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Affiliation(s)
- Robert B Laverty
- From the Department of Surgery (R.B.L.), Brooke Army Medical Center, JBSA Fort Sam Houston; University of the Incarnate Word School of Medicine (R.N.T.), San Antonio; Vascular Surgery Service (D.S.K.), Brooke Army Medical Center, JBSA Fort Sam Houston, Texas; and Department of Surgery (D.S.K.), Uniformed Services University, Bethesda, Maryland
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9
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Fujioka M, Fukui K, Noguchi M. The Efficacy of Salvage Intervention with Emergency Transient External Arterial Bypass for Traumatic Artery Occlusion of Main Extremities. J Emerg Trauma Shock 2022; 15:56-59. [PMID: 35431483 PMCID: PMC9006713 DOI: 10.4103/jets.jets_88_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 09/21/2021] [Accepted: 10/26/2021] [Indexed: 11/04/2022] Open
Abstract
Even if the vascular repair is successful, the frequency of limb loss is still high when popliteal artery injury is associated with postischemic syndrome due to blunt trauma or a prolonged ischemic time. Because prolonged ischemia interferes with an injured foot rescue, shortening of the ischemic time is a major aim of surgeons. We present two types of transient external arterial bypass and two cases of ischemic extremities due to main arterial injury. Even though the injured extremities had no circulation for more than 6 h, a transient external arterial bypass supplied circulation immediately, and they were reconstructed successfully. Although transient external arterial bypass is a dated technique, it is a recommended option, especially in the management of acute traumatic ischemia of the extremities to shorten the ischemic time and provide immediate reperfusion, which will bring the opportunity to save the ischemic limbs.
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Affiliation(s)
- Masaki Fujioka
- Department of Plastic and Reconstructive Surgery, Nagasaki University, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan.,Department of Plastic and Reconstructive Surgery, Clinical Research Center, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Kiyoko Fukui
- Department of Plastic and Reconstructive Surgery, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Miho Noguchi
- Department of Plastic and Reconstructive Surgery, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
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10
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Ali G, Berlas MF, Din NU, Rehman KU, Muhammad Saleh W, Naqvi SAA. Outcomes of Revascularization and Factors Associated With Major Amputation in Patients With Lower Limb Arterial Injury: A Single-Center Retrospective Analysis. Cureus 2021; 13:e17290. [PMID: 34567854 PMCID: PMC8452226 DOI: 10.7759/cureus.17290] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2021] [Indexed: 11/05/2022] Open
Abstract
Objective To identify the amputation rates and causative factors for failed revascularization leading to amputation in patients undergoing primary limb salvage procedures for lower-extremity vascular injuries. Methods This retrospective study was conducted at the vascular surgery department, Shaheed Mohtarma Benazir Bhutto (SMBB) Institute of Trauma, Karachi, Pakistan. The data were collected from hospital record using the non-probability sampling technique. Patients aged 17-70 years, undergoing primary revascularization during April 2016 to March 2021, were included in the study. Patients with crush injuries/non-salvageable limbs underwent primary amputation, isolated deep femoral artery or crural arteries (non-limb threatening) injuries, and non-traumatic injuries like intravenous drug-induced or iatrogenic injuries were excluded. The data analysis is done using SPSS Version 20.0 (IBM Corp., Armonk, NY, USA). A P-value of <0.05 was considered as significant. Results This study includes 56 patients of mean age 30.82 ± 9.29 years with male gender four times more affected than their counterpart. About 32% of patients were smokers, while 58% of patients had no co-morbidities. All patients presented with a mean time of 7.66 ± 1.69 hours of injury with an average of 1.14 arterial segments involved. The most frequent artery involved was popliteal artery (both above and below the knee), followed by superficial femoral artery injury constituting 50% and 26%, respectively, with arterial laceration and transection being common findings on exploration. Out of 56 patients, 27 (48.2%) had open fractures, 21 (37.5% ) closed fractures, and eight patients (14.3 % ) presented with dislocation as associated injuries. Following the procedure, secondary amputation was recorded in 18 (32.1%) patients. Thrombosis and infection were the leading causes of revascularization failure. Type of injury, segment of arterial injury, and associated bony injuries were associated with limb amputation. Conclusion Type and site of injury along with concomitant bony injuries are associated with major amputations after revascularization in lower-extremity arterial injuries.
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Affiliation(s)
- Ghulam Ali
- Vascular Surgery, Shaheed Mohtarma Benazir Bhutto Institute of Trauma, Karachi, PAK
| | | | - Najam U Din
- Vascular Surgery, Shaheed Mohtarma Benazir Bhutto Institute of Trauma, Karachi, PAK
| | - Khalil Ur Rehman
- Vascular Surgery, Shaheed Mohtarma Benazir Bhutto Institute of Trauma, Karachi, PAK
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11
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Hundersmarck D, Hietbrink F, Leenen LPH, De Borst GJ, Heng M. Blunt popliteal artery injury following tibiofemoral trauma: vessel-first and bone-first strategy. Eur J Trauma Emerg Surg 2021; 48:1045-1053. [PMID: 33743028 PMCID: PMC9001538 DOI: 10.1007/s00068-021-01632-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 02/26/2021] [Indexed: 12/01/2022]
Abstract
Purpose Blunt popliteal artery injury (BPAI) is a potentially limb-threatening sequela of tibiofemoral (knee) dislocations and fractures. Associated amputation rates for all popliteal artery (PA) injuries range between 10 and 50%. It is unclear whether PA repair or bone stabilization should be performed first. We analyzed (long-term) clinical outcomes of BPAI patients that received initial PA repair (vessel-first, VF) versus initial external stabilization (bone-first, BF). Methods Retrospectively, all surgically treated BPAI patients between January 2000 and January 2019, admitted to two level 1 trauma centers were included. Clinical outcomes were determined, stratified by initial management strategy (VF and BF). Treatment strategy was determined by surgeon preference, based on associated injuries and ischemia duration. Primary outcomes (amputation and mortality) and secondary outcomes (claudication and complications) were determined. Results Of 27 included BPAI patients, 15 were treated according to the VF strategy (56%) and 12 according to the BF strategy (44%). Occlusion was the most frequently encountered BPAI in 18/27 patients (67%). Total delay and in-hospital delay were comparable between groups (p = 1.00 and p = 0.82). Revascularization was most frequently performed by PA bypass (59%). All patients had primary limb salvage during admission (100%). One secondary amputation due to knee pain was performed in the BF group (4%). During a median clinical follow-up period of 2.7 years, three PA re-interventions were performed, two in the BF group and one in the VF group. None suffered from (intermittent) claudication. Conclusion Blunt popliteal artery injury (BPAI) is a rare surgical emergency. Long-term outcomes of early revascularization for BPAI appear to be good, independent of initial management strategy. The BF strategy may be preferred in case of severe orthopedic injury, if allowed by total ischemia duration. Supplementary Information The online version contains supplementary material available at 10.1007/s00068-021-01632-0.
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Affiliation(s)
- Dennis Hundersmarck
- Department of Orthopedic Surgery, Harvard Medical School Orthopedic Trauma Initiative, Massachusetts General Hospital, 55 Fruit Street, Boston, USA. .,Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Falco Hietbrink
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Luke P H Leenen
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gert J De Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marilyn Heng
- Department of Orthopedic Surgery, Harvard Medical School Orthopedic Trauma Initiative, Massachusetts General Hospital, 55 Fruit Street, Boston, USA
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The Ethical Triage and Management Guidelines of the Entrapped and Mangled Extremity in Resource Scarce Environments: A Systematic Literature Review. Disaster Med Public Health Prep 2020; 15:389-397. [PMID: 32456743 DOI: 10.1017/dmp.2020.49] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE A systematic literature review (SLR) was performed to elucidate the current triage and treatment of an entrapped or mangled extremity in resource scarce environments (RSEs). METHODS A lead researcher followed the search strategy following inclusion and exclusion criteria. A first reviewer (FR) was randomly assigned sources. One of the 2 lead researchers was the second reviewer (SR). Each determined the level of evidence (LOE) and quality of evidence (QE) from each source. Any differing opinions between the FR and SR were discussed between them, and if differing opinions remained, then a third reviewer (the other lead researcher) discussed the article until a consensus was reached. The final opinion of each article was entered for analysis. RESULTS Fifty-eight (58) articles were entered into the final study. There was 1 study determined to be LOE 1, 29 LOE 2, and 28 LOE 3, with 15 determined to achieve QE 1, 37 QE 2, and 6 QE 3. CONCLUSION This SLR showed that there is a lack of studies producing strong evidence to support the triage and treatment of the mangled extremity in RSE. Therefore, a Delphi process is suggested to adapt and modify current civilian and military triage and treatment guidelines to the RSE.
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Musonza T, Khouqeer A, Gilani R. Bilateral popliteal artery injury: Lessons learned. Trauma Case Rep 2019; 23:100230. [PMID: 31388540 PMCID: PMC6669397 DOI: 10.1016/j.tcr.2019.100230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2019] [Indexed: 11/19/2022] Open
Abstract
Popliteal artery trauma is reported to have the highest rates of limb loss in peripheral vascular injuries. It can be inferred that morbidity associated with bilateral popliteal artery trauma is worse. However, bilateral popliteal artery injuries are sparsely reported in literature and as such management options are not well defined. Despite the paucity of reported cases, a systematic and deliberate approach to these devastating injuries may result in reproducible limb salvage. We hereby use our case report as a provocateur to this conundrum. Consideration should be given to the utilization of surgical shunts or a two-surgical team and limb salvage attempted till proving the neurovascular bundle irreparable. Arterial grafts should be part of the surgeon's armamentarium. In massive hard to control hemorrhage, tourniquets or resuscitative endovascular occlusion devices (REBOA) may prove lifesaving. Larger studies are needed to define contemporary management and derive management guidelines.
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Affiliation(s)
- Tashinga Musonza
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States of America
- Corresponding author at: Michael E. DeBakey Department of Surgery, Baylor College of Medicine, BCM One Baylor Plaza, Suite 404D, Houston, TX 77030, United States of America.
| | - Ahmed Khouqeer
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States of America
| | - Ramyar Gilani
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States of America
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Teissier V, Tresson P, Gaudric J, Davaine JM, Scemama C, Raux M, Chiche L, Koskas F. Importance of Early Diagnosis and Care in Knee Dislocations Associated with Vascular Injuries. Ann Vasc Surg 2019; 61:238-245. [PMID: 31344468 DOI: 10.1016/j.avsg.2019.04.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 04/04/2019] [Accepted: 04/06/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Arterial injury secondary to acute knee dislocation (KD) is a rare but devastative complication. The aim of this study is to evaluate functional sequelae and factors of poor prognosis. METHODS A retrospective monocentric series of consecutive KD with acute ischemia by popliteal artery injury was analyzed between 2005 and 2017. The main outcome was the amputation rate. RESULTS Sixteen dislocations were included. Nine (56%) were due to public road accidents, 5 (31%) were due to falls from height, and 2 (13%) were due to sports injuries. Dislocation had occurred in the posterior location in 8 (50%) cases. Regarding arterial injury, there were 7 (44%) ruptures, 7 (44%) dissections, and 2 (13%) isolated thromboses. Eleven (69%) KDs with vascular trauma were associated with signs of acute ischemia. Revascularization was achieved by anatomical venous bypass in 14 (88%), resection and direct anastomosis in one (6%), and isolated thrombectomy in one (6%). Median time to surgery (time between trauma and vascular repair) was 7 hours (3.25-60.92 hours). Primary revascularization was performed in 12 (75%) cases. In three cases (19%), orthopedic reduction and stabilization were performed first. In one case, (6%) three-step management with vascular shunt at first, then with knee stabilization, and finally vascular bypass was carried out. Stabilization was achieved by using an external fixator in 13 (82%) cases, by open reduction and internal fixation in one case (6%), by ligamentoplasty in one (6%), and by using a long leg cast in one (6%). Fasciotomy was required in 12 (75%) cases. Two patients had early vascular complications, and 2 had early systemic complications. Three secondary transfemoral amputations were performed. Median follow-up duration was 23 months. No secondary amputation was recorded. At the end of follow-up, functional outcomes were evaluated using the Oxford Knee Score (OKS). The median OKS was 30 versus the pretrauma median OKS of 47 (P < 0.00028). No risk factor associated with limb amputation has been highlighted. CONCLUSIONS Analysis of these results provided indications for therapeutic management of this condition. This study shows poor functional outcomes because of severity of vascular lesion in patients with orthopedic trauma but with healthy arteries.
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Affiliation(s)
- Victoria Teissier
- Department of Vascular Surgery, Groupe Hospitalier Pitié-Salpétrière Charles Foix, APHP, Université Paris6, Paris, France
| | - Philippe Tresson
- Department of Vascular Surgery, Groupe Hospitalier Pitié-Salpétrière Charles Foix, APHP, Université Paris6, Paris, France.
| | - Julien Gaudric
- Department of Vascular Surgery, Groupe Hospitalier Pitié-Salpétrière Charles Foix, APHP, Université Paris6, Paris, France
| | - Jean-Michel Davaine
- Department of Vascular Surgery, Groupe Hospitalier Pitié-Salpétrière Charles Foix, APHP, Université Paris6, Paris, France
| | - Caroline Scemama
- Department of Orthopaedic Surgery, Groupe Hospitalier Pitié-Salpétrière Charles Foix, APHP, Université Paris6, Paris, France
| | - Mathieu Raux
- Sorbonne Université, INSERM, UMRS1158, Neurophysiologie respiratoire expérimentale et clinique, Paris, France; AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Département d'Anesthésie Réanimation, Paris, France
| | - Laurent Chiche
- Department of Vascular Surgery, Groupe Hospitalier Pitié-Salpétrière Charles Foix, APHP, Université Paris6, Paris, France
| | - Fabien Koskas
- Department of Vascular Surgery, Groupe Hospitalier Pitié-Salpétrière Charles Foix, APHP, Université Paris6, Paris, France
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Romagnoli A, DuBose J, Brenner M. Damage Control Vascular Surgery. CURRENT TRAUMA REPORTS 2019. [DOI: 10.1007/s40719-019-00172-8] [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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16
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Ibrahim MAA, Elwan WM, Elgendy HA. Role of Scutellarin in Ameliorating Lung Injury in a Rat Model of Bilateral Hind Limb Ischemia–Reperfusion. Anat Rec (Hoboken) 2019; 302:2070-2081. [DOI: 10.1002/ar.24175] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 03/24/2019] [Accepted: 04/01/2019] [Indexed: 12/15/2022]
Affiliation(s)
- Marwa A. A. Ibrahim
- Histology and Cell Biology Department, Faculty of MedicineTanta University Tanta Egypt
| | - Walaa M. Elwan
- Histology and Cell Biology Department, Faculty of MedicineTanta University Tanta Egypt
| | - Hanan A. Elgendy
- Anatomy and Embryology Department, Faculty of MedicineMansoura University Mansoura Egypt
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17
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Usman R, Jamil M, Anwer MF. Evaluation, Surgical Management and Outcome of Traumatic Extremity Vascular Injuries: A 5-year Level-1 Trauma Centres Experience. Ann Vasc Dis 2018; 11:312-317. [PMID: 30402181 PMCID: PMC6200616 DOI: 10.3400/avd.oa.18-00068] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objective: We aim to share our experience regarding the surgical management and outcome of extremity vascular trauma in level-1 trauma centres in Pakistan. Patients and methods: All consecutive patients with traumatic extremity vascular injury (TEVI) fulfilling the inclusion criteria; between June 2012 and June 2017 were included. The demographics, clinical presentation, management, and outcome measures were recorded. Results: The study included 81 patients. The mean age±standard deviation was 28.6±14.5 years and 81.5% (n=66) of the patients were males. Blunt TEVI was found in 65.4% (n=53) of the cases. Partial laceration was the most common type of arterial injury (64.2%, n=52) and autologous interposition venous grafting was the most common repair performed (60.5%, n=49). Fasciotomy was performed in 67.9% (n=55) of the patients. The limb salvage rate was 82.7%. The amputation rate was higher in the blunt trauma group when compared with that of the penetrating trauma group. The length of the intensive care unit stay and the use of polytetrafluoroethylene as interposition graft were two independent predictors of limb loss. The mortality rate in this series was 8.6%. Conclusion: Blunt TEVI is associated with higher morbidity and limb loss. The use of synthetic graft should be discouraged. The liberal use of autologous interposition venous graft and the judicious use of fasciotomies are helpful to achieve favorable outcomes.
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Affiliation(s)
- Rashid Usman
- Department of Vascular Surgery, Combined Military Hospital, Lahore Cantt, Pakistan
| | - Muhammad Jamil
- Department of Vascular Surgery, Combined Military Hospital, Peshawar Cantt, Pakistan
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Wu Y, Zhang MH, Xue Y, Zhang T, Wu N, Guo W, Du X, Xu YL. Effect of microRNA-26a on vascular endothelial cell injury caused by lower extremity ischemia-reperfusion injury through the AMPK pathway by targeting PFKFB3. J Cell Physiol 2018; 234:2916-2928. [PMID: 30132885 DOI: 10.1002/jcp.27108] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 06/28/2018] [Indexed: 12/23/2022]
Abstract
Vascular endothelial cell (VEC) dysfunction plays an important role in the ischemia-reperfusion injury (IRI)-related diseases, and microRNAs (miRNAs) are key factors during this process. We conducted this study to investigate whether miRNA-26a (miR-26a) has effect on the IRI-induced VEC injury via the AMPK pathway by targeting 6-phosphofructo-2-kinase-fructose-2,6-biphosphatase 3 (PFKFB3). IRI rat models were successfully constructed by an abdominal incision. Additionally, the cultured VECs were further treated with miR-26a mimic or inhibitor, and si-PFKFB3. Both the reverse-transcription quantitative polymerase chain reaction and the western blot assay method were carried out to examine the expressions of PFKFB3, endothelial nitric oxide synthase (eNOS), and 5'-adenosine monophosphate-activated protein kinase (AMPK) α1, as well as the extent of the AMPK α1 phosphorylation levels in vascular tissues. Circulating endothelial cell (CEC), von Willebrand factor (VWF), thrombomodulin (TM), superoxide dismutase (SOD), malondialdehyde (MDA), nitric oxide (NO), and endothelin (ET) were all measured. In the rat model of an IRI, a poorly expressed miR-26a and contrarily highly expressed PFKFB3 were identified in vascular tissues. In response to an overexpression of miR-26a or to the PFKFB3 gene silencing, decreased CEC number, TM, VWF, MDA, and ET contents, increased AMPK α1, and eNOS levels, as well as the extent of AMPK α1 phosphorylation coordinate with both increased SOD and NO contents based on the restoration of the AMPK pathway. Overexpression of the miR-26a or si-PFKFB3 provides an elevation in cell proliferation. Our study suggests that the miR-26a RNA alleviates lower extremity IRI-induced VEC injury in rats through the activation of the AMPK pathway by inhibiting PFKFB3.
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Affiliation(s)
- Ye Wu
- Department of Vascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Min-Hong Zhang
- Department of Vascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Yan Xue
- Department of Vascular Surgery, Chinese PLA General Hospital, Beijing, China.,Department of Cardiovascular Surgery, General Hospital of Armed Police Forces, Beijing, China
| | - Tao Zhang
- Department of Vascular Surgery, Peking University People's Hospital, Beijing, China
| | - Na Wu
- Department of Central Laboratory, Institute of Clinical Molecular Biology, Peking University People's Hospital, Beijing, China
| | - Wei Guo
- Department of Cardiovascular Surgery, Chinese PLA Rocket Force General Hospital, Beijing, China
| | - Xin Du
- Department of Vascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Yong-Le Xu
- Department of Vascular Surgery, Chinese PLA General Hospital, Beijing, China
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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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20
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Abou Ali AN, Salem KM, Alarcon LH, Bauza G, Pikoulis E, Chaer RA, Avgerinos ED. Vascular Shunts in Civilian Trauma. Front Surg 2017; 4:39. [PMID: 28775985 PMCID: PMC5517780 DOI: 10.3389/fsurg.2017.00039] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 07/05/2017] [Indexed: 11/25/2022] Open
Abstract
Experience with temporary intravascular shunts (TIVS) for vessel injury comes from the military sector and while the indications might be clear in geographically isolated and under resourced war zones, this may be an uncommon scenario in civilian trauma. Data supporting TIVS use in civilian trauma have been extrapolated from the military literature where it demonstrated improved life and limb salvage. Few non-comparative studies from the civilian literature have also revealed similar favorable outcomes. Still, TIVS placement in civilian vascular injuries is uncommon and by some debatable given the absence of clear indications for placement, the potential for TIVS-related complications, the widespread resources for immediate and definitive vascular repair, and the need for curtailing costs and optimizing resources. This article reviews the current evidence and the role of TIVS in contemporary civilian trauma management.
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Affiliation(s)
- Adham N Abou Ali
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Karim M Salem
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Louis H Alarcon
- Division of Trauma and General Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Graciela Bauza
- Division of Trauma and General Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Emmanuel Pikoulis
- Uniformed Services University of Health Sciences, Bethesda, MD, United States
| | - Rabih A Chaer
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
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Abstract
BACKGROUND Arterial shunting is a well-described method to control hemorrhage and rapidly reestablish flow, but optimal shunt dwell times remain controversial. We hypothesized that prolonged shunt dwell times of more than 6 hours are related to adverse outcomes after major arterial injury. METHODS A review (2005-2013) of all patients with arterial shunts placed after traumatic injury at our urban Level I trauma center was undertaken. Patients who died prior to shunt removal (n = 7) were excluded. Shunt complications were defined as dislodgement, thrombosis, and distal ischemia. Patients were compared on the basis of shunt complications with respect to clinical parameters. RESULTS The 42 patients who underwent arterial shunting after major vascular injury were primarily young (median, 26 years; interquartile range [IQR], 22-31 years) males (97.6%), severely injured (Injury Severity Score, 17.5 [IQR, 14-29]; shunted vessel Abbreviated Injury Scale score, 4 [IQR, 3-4]) by gunshot (85.7%) requiring neck/torso (33.3%) or upper-extremity (19.1%) or lower-extremity (47.6%) shunts. Thirty-five patients survived until shunt removal, and 5 (14.3%) of 35 developed shunt complications. Demographics and clinical characteristics were compared between those with shunt dwell times of less than 6 hours (n = 19) and more than 6 hours (n = 16). While patients appeared to have a greater injury burden overall in the group with dwell times of more than 6 hours, there were no statistical differences between groups with respect to age, gender, initial systolic blood pressure or hemodynamics during the shunt dwell period, use of vasopressors, Abbreviated Injury Scale score of the shunted vessel, Injury Severity Score, or outcomes including limb amputation or mortality. No patients (0/19) with shunt dwell times of less than 6 hours developed complications, whereas 5 (31.3%) of 16 patients with dwell times of more than 6 hours developed shunt complications (p = 0.05). CONCLUSIONS In this civilian series, 14% of patients with arterial shunts developed shunt complications. Our data suggest that limiting shunt dwell times to less than 6 hours when clinically feasible may decrease adverse outcomes. LEVEL OF EVIDENCE Therapeutic/care management study, level IV.
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Góes Junior AMDO, Abib SDCV, Alves MTDS, Ferreira PSVDS, Andrade MCD. Venous Shunt Versus Venous Ligation for Vascular Damage Control: The Immunohistochemical Evidence. Ann Vasc Surg 2017; 41:214-224. [PMID: 28163177 DOI: 10.1016/j.avsg.2016.10.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 06/09/2016] [Accepted: 10/17/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND To evaluate the expression of immunohistochemical markers of tissue ischemia (iNOS, eNOS, and HSP70) in a vascular damage control experimental model to determine if a venous temporary vascular shunt insertion leads to a better limb perfusion when compared with the ligature of the injured vein. METHODS Experimental study in male Sus Scrofa weighting 40 Kg. Animals were distributed into 5 groups: group 1 animals were submitted to right external iliac artery (EIA) shunting and right external iliac vein (EIV) ligation; group 2 animals were submitted to right EIA shunting and right EIV shunting; group 3 animals were submitted to right EIV ligation; group 4 animals were submitted to right EIV shunting; group 5 animals were not submitted to vascular shunting or venous ligation. Transonic Systems flowmeters were used to measure vascular flow on right and left external iliac vessels, and i-STAT (Abbot) portable blood analyzer was used for EIVs blood biochemical analysis. An initial baseline register of invasive arterial pressure, iliac vessels flow, and venous blood analysis was performed. Arterial pressure and iliac vessels flow were taken immediately after right iliac vessels shunting or ligation. Then, hemorrhagic shock was induced by continuous 20 mL/min blood withdraw from the external right jugular vein whereas arterial blood pressure and iliac vessels flow registers were taken every 10 min, and blood samples from EIVs were obtained every 30 min until the vascular flow through right EIA (or through the shunt inserted into the right EIV for group 4 animals) became inexistent or until the animal's death. After the end of the experiments, bilateral hind limb's biopsies were obtained for immunohistochemical analysis. Using image editing and analysis software, the expression of iNOS, eNOS, and HSP70 (3 well-known ischemic associated immunohistochemical markers) was assessed. The mean expression of each marker in the right hind limb was compared between groups. For statistical analysis, Microsoft Office Excel 2007 and BioEstat 5.0 (2007) were used. RESULTS Immunohistochemical analysis showed no difference regarding the iNOS expression; nevertheless, both eNOS and HSP70 expression were statistically more intense (P < 0.05) on group 1 (eNOS = 1.32; HSP70 = 15.05) than on group 2 (eNOS = 0.018; HSP70 = 8.56). CONCLUSIONS The higher expression of eNOS and HSP70 in the right hind limbs of group 1 animals (arterial shunt and venous ligature) than group 2 animals (arterial shunt and venous shunt) suggests that venous ligation is associated with more intense ischemic histological findings than venous shunting.
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Davins M, Llagostera S, Lamas C, López S. Role of Temporary Arterial Shunt in the Reimplantation of a Traumatic Above-Elbow Amputation. Vascular 2016; 15:176-8. [PMID: 17573026 DOI: 10.2310/6670.2007.00023] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Although the feasibility of reimplantation has increased greatly with the development of new surgical techniques, long-term functional prognosis is unpredictable. Injury to a major nerve is an important factor in long-term outcome, and prolonged ischemia time also has a negative effect. We present a 26-year-old woman whose right arm was sectioned above the elbow in an accident. The limb presented a complete section, with soft tissue loss of the humeral artery and vein, basilic vein, and cephalic vein. Median and radial nerve tissue was missing, and a supracondylar fracture with substantial loss of the humerus was also observed. During reimplantation surgery, a temporary arterial shunt reduced ischemia time. A venous and arterial bypass was performed, and the 12-month results were good.
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Affiliation(s)
- Meritxell Davins
- Department of Vascular Surgery, Sana Creu i Sant Pau Hospital, Barcelona, Spain.
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Cepharanthine mitigates lung injury in lower limb ischemia–reperfusion. J Surg Res 2015; 199:647-56. [DOI: 10.1016/j.jss.2015.06.041] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 05/25/2015] [Accepted: 06/17/2015] [Indexed: 11/23/2022]
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Caffeine Mitigates Lung Inflammation Induced by Ischemia-Reperfusion of Lower Limbs in Rats. Mediators Inflamm 2015; 2015:361638. [PMID: 26648663 PMCID: PMC4663348 DOI: 10.1155/2015/361638] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 10/28/2015] [Accepted: 11/04/2015] [Indexed: 12/21/2022] Open
Abstract
Reperfusion of ischemic limbs can induce inflammation and subsequently cause acute lung injury. Caffeine, a widely used psychostimulant, possesses potent anti-inflammatory capacity. We elucidated whether caffeine can mitigate lung inflammation caused by ischemia-reperfusion (IR) of the lower limbs. Adult male Sprague-Dawley rats were randomly allocated to receive IR, IR plus caffeine (IR + Caf group), sham-operation (Sham), or sham plus caffeine (n = 12 in each group). To induce IR, lower limbs were bilaterally tied by rubber bands high around each thigh for 3 hours followed by reperfusion for 3 hours. Caffeine (50 mg/kg, intraperitoneal injection) was administered immediately after reperfusion. Our histological assay data revealed characteristics of severe lung inflammation in the IR group and mild to moderate characteristic of lung inflammation in the IR + Caf group. Total cells number and protein concentration in bronchoalveolar lavage fluid of the IR group were significantly higher than those of the IR + Caf group (P < 0.001 and P = 0.008, resp.). Similarly, pulmonary concentrations of inflammatory mediators (tumor necrosis factor-α, interleukin-1β, and macrophage inflammatory protein-2) and pulmonary myeloperoxidase activity of the IR group were significantly higher than those of the IR + Caf group (all P < 0.05). These data clearly demonstrate that caffeine could mitigate lung inflammation induced by ischemia-reperfusion of the lower limbs.
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Imerci A, Ozaksar K, Gürbüz Y, Sügün TS, Canbek U, Savran A. Popliteal artery injury associated with blunt trauma to the knee without fracture or dislocation. West J Emerg Med 2015; 15:145-8. [PMID: 24672601 PMCID: PMC3966444 DOI: 10.5811/westjem.2013.12.18223] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Revised: 11/26/2013] [Accepted: 12/05/2013] [Indexed: 12/05/2022] Open
Abstract
Popliteal artery injuries are frequently seen with fractures, dislocations, or penetrating injuries. Concern about arterial injury and early recognition of the possibility of arterial injury is crucial for the salvage of the extremity. This article provides an outline of the diagnostic challenges related to these rare vascular injuries and emphasizes the necessity for a high level of suspicion, even in the absence of a significant penetrating injury, knee dislocation, fracture, or high-velocity trauma mechanism. The importance of a detailed vascular examination of a blunt trauma patient is emphasized.
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Affiliation(s)
- Ahmet Imerci
- Erzurum Palandoken State Hospital, Department of Orthopaedics and Traumatology, Erzurum, Turkey
| | - Kemal Ozaksar
- Hand Microsurgery Orthopaedic Traumatology (EMOT) Hospital, Izmir, Turkey
| | - Yusuf Gürbüz
- Hand Microsurgery Orthopaedic Traumatology (EMOT) Hospital, Izmir, Turkey
| | - Tahir Sadik Sügün
- Hand Microsurgery Orthopaedic Traumatology (EMOT) Hospital, Izmir, Turkey
| | - Umut Canbek
- Mugla Sitki Kocman University of Medicine, Department of Orthopaedics and Traumatology, Mugla, Turkey
| | - Ahmet Savran
- Izmir Tepecik Education and Research Hospital, Department of Orthopaedics and Traumatology, Turkey
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Hornez E, Boddaert G, Ngabou UD, Aguir S, Baudoin Y, Mocellin N, Bonnet S. Temporary vascular shunt for damage control of extremity vascular injury: A toolbox for trauma surgeons. J Visc Surg 2015; 152:363-8. [PMID: 26456452 DOI: 10.1016/j.jviscsurg.2015.09.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
In an emergency, a general surgeon may be faced with the need to treat arterial trauma of the extremities when specialized vascular surgery is not available in their hospital setting, either because an arterial lesion was not diagnosed during pre-admission triage, or because of iatrogenic arterial injury. The need for urgent control of hemorrhage and limb ischemia may contra-indicate immediate transfer to a hospital with a specialized vascular surgery service. For a non-specialized surgeon, hemostasis and revascularization rely largely on damage control techniques and the use of temporary vascular shunts (TVS). Insertion of a TVS is indicated for vascular injuries involving the proximal portion of extremity vessels, while hemorrhage from distal arterial injuries can be treated with simple arterial ligature. Proximal and distal control of the injured vessel must be obtained, followed by proximal and distal Fogarty catheter thrombectomy and lavage with heparinized saline. The diameter of the TVS should be closely approximated to that of the artery; use of an oversized TVS may result in intimal tears. Systematic performance of decompressive fasciotomy is recommended in order to prevent compartment syndrome. In the immediate postoperative period, the need for systematic use of anticoagulant or anti-aggregant medications has not been demonstrated. The patient should be transferred to a specialized center for vascular surgery as soon as possible. The interval before definitive revascularization depends on the overall condition of the patient. The long-term limb conservation results after placement of a TVS are identical to those obtained when initial revascularization is performed.
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Affiliation(s)
- E Hornez
- Hôpital d'Instruction des Armées Percy, Clamart, France.
| | - G Boddaert
- Hôpital d'Instruction des Armées Percy, Clamart, France
| | - U D Ngabou
- Hôpital d'Instruction des Armées Percy, Clamart, France
| | - S Aguir
- Hôpital d'Instruction des Armées Percy, Clamart, France
| | - Y Baudoin
- Hôpital d'Instruction des Armées Percy, Clamart, France
| | - N Mocellin
- Hôpital d'Instruction des Armées Percy, Clamart, France
| | - S Bonnet
- Hôpital d'Instruction des Armées Percy, Clamart, France
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Hornez E, Boddaert G, Baudoin Y, Daban JL, Ollat D, Ramiara P, Bonnet S. Concomitant Vascular War Trauma Saturating a French Forward Surgical Team Deployed to Support the Victims of the Syrian War (2013). Interest of the Vascular Damage Control. Ann Vasc Surg 2015; 29:1656.e7-12. [PMID: 26362619 DOI: 10.1016/j.avsg.2015.04.094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 03/10/2015] [Accepted: 04/15/2015] [Indexed: 10/23/2022]
Abstract
Vascular injuries from war require an emergency treatment whose objective is to quickly obtain hemostasis and the restoration of arterial flow. In this context of heavy trauma and limited means, damage control surgery is recommended and is based on the use of temporary vascular shunts (TVSs). We report the management of the simultaneous arrival of 2 vascular injuries of war in a field hospital. Patient 1 presented a ballistic trauma of the elbow with a section of the humeral artery (Gustillo IIIC). A TVS was set up during the external fixation of the elbow. Final revascularization was carried out and aponevrotomies of the forearm were performed. Patient 2 had a riddled knee with an open fracture of the femur, an avulsion of the popliteal artery, and a hemorrhagic shock. A strategy of damage control surgery was carried out with placing an arterial and venous shunt. Aponevrotomies of the leg were carried out before casting. For the traumatisms of the arteries of the members, the use of shunts is reserved for the lesions of the proximal vessels. Many vascular shunts available have the same performances to restore the arterial flow and prevent secondary thrombosis. The time before the final revascularization depends on the clinical condition of the patient. The value of anticoagulation in these cases was not shown.
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Affiliation(s)
- Emmanuel Hornez
- Service de chirurgie viscérale et thoracique, Hôpital d'Instruction des Armées Percy, Clamart, France.
| | - Guillaume Boddaert
- Service de chirurgie viscérale et thoracique, Hôpital d'Instruction des Armées Percy, Clamart, France
| | - Yoann Baudoin
- Service de chirurgie viscérale et thoracique, Hôpital d'Instruction des Armées Percy, Clamart, France
| | - Jean Louis Daban
- Département d'anesthésie et réanimation, Hôpital d'Instruction des Armées Percy, Clamart, France
| | - Didier Ollat
- Service de chirurgie orthopédique, Hôpital d'Instruction des Armées Begin, Toulon, France
| | - Patrice Ramiara
- Département d'anesthésie et réanimation, Hôpital d'Instruction des Armées Sainte Anne, Toulon, France
| | - Stéphane Bonnet
- Service de chirurgie viscérale et thoracique, Hôpital d'Instruction des Armées Percy, Clamart, France
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Sciarretta JD, Macedo FIB, Otero CA, Figueroa JN, Pizano LR, Namias N. Management of traumatic popliteal vascular injuries in a level I trauma center: A 6-year experience. Int J Surg 2015; 18:136-41. [DOI: 10.1016/j.ijsu.2015.04.056] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Revised: 02/21/2015] [Accepted: 04/21/2015] [Indexed: 12/12/2022]
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30
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Characteristics and clinical outcome in patients after popliteal artery injury. J Vasc Surg 2015; 61:1495-500. [DOI: 10.1016/j.jvs.2015.01.045] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 01/23/2015] [Indexed: 10/23/2022]
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31
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Chang SW, Han S, Ryu KM, Ryu JW. Management of Femoropopliteal Vascular Injuries after Trauma: Surgical Outcomes. JOURNAL OF TRAUMA AND INJURY 2015. [DOI: 10.20408/jti.2015.28.1.15] [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)
- Sung Wook Chang
- Trauma Center, , Dankook University Hospital
- Department of Thoracic and Cardiovascular Surgery, Dankook University Hospital
| | - Sun Han
- Department of Thoracic and Cardiovascular Surgery, Dankook University Hospital
| | - Kyoung Min Ryu
- Department of Thoracic and Cardiovascular Surgery, Dankook University Hospital
| | - Jae-Wook Ryu
- Department of Thoracic and Cardiovascular Surgery, Dankook University Hospital
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Vielgut I, Gregori M, Holzer LA, Glehr M, Hashemi S, Platzer P. Limb salvage and functional outcomes among patients with traumatic popliteal artery injury: a review of 64 cases. Wien Klin Wochenschr 2015; 127:561-6. [DOI: 10.1007/s00508-015-0715-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 01/19/2015] [Indexed: 11/28/2022]
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Macedo FIB, Sciarretta JD, Salsamendi J, Karmacharya J, Romano A, Namias N. Repair of an Acute Blunt Popliteal Artery Trauma via Endovascular Approach. Ann Vasc Surg 2015; 29:366.e5-366.e10. [DOI: 10.1016/j.avsg.2014.10.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 09/26/2014] [Accepted: 10/04/2014] [Indexed: 12/14/2022]
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34
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Österberg K, Falkenberg M, Resch T. Endovascular Technique for Arterial Shunting to Prevent Intraoperative Ischemia. Eur J Vasc Endovasc Surg 2014; 48:126-30. [DOI: 10.1016/j.ejvs.2014.04.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 04/14/2014] [Indexed: 11/25/2022]
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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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36
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Management of major limb injuries. ScientificWorldJournal 2014; 2014:640430. [PMID: 24511296 PMCID: PMC3913364 DOI: 10.1155/2014/640430] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Accepted: 10/02/2013] [Indexed: 12/16/2022] Open
Abstract
Management of major limb injuries is a daunting challenge, especially as many of these patients have severe associated injuries. In trying to save life, often the limb is sacrificed. The existing guidelines on managing such trauma are often confusing. There is scope to lay down such protocols along with the need for urgent transfer of such patients to a multispecialty center equipped to salvage life and limb for maximizing outcome. This review article comprehensively deals with the issue of managing such major injuries.
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Sciarretta JD, Perez-Alonso AJ, Ebler DJ, Mazzini FN, Petrone P, Asensio-Gonzalez JA. Popliteal vessel injuries: complex anatomy, difficult problems and surgical challenges. Eur J Trauma Emerg Surg 2012; 38:373-91. [PMID: 26816119 DOI: 10.1007/s00068-012-0217-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2012] [Accepted: 07/03/2012] [Indexed: 11/30/2022]
Abstract
The incidence of popliteal vessel injuries is low, even in busy urban trauma centers. As a result of this fact, few trauma centers and trauma surgeons have developed extensive experience in the management of these injuries. Popliteal vessel injuries in both civilian and military arenas incur significant morbidity. These injuries present a difficult challenge, and, although the overall incidence of these injuries remains low, the sequelae can be devastating. Successful outcomes for limb salvage and survival result from early recognition and rapid surgical intervention by a multidisciplinary approach with a great participation of different surgical specialties. From the historical perspective, anatomy, incidence and associated injuries, to the clinical presentation, diagnosis, management, and morbidity and mortality, the aim of this article is to review the various aspects of these complex injuries.
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Affiliation(s)
- J D Sciarretta
- Division of Trauma Surgery and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, Education and Training International Medicine Institute, Miller School of Medicine, University of Miami, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - A J Perez-Alonso
- Division of Trauma Surgery and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, Education and Training International Medicine Institute, Miller School of Medicine, University of Miami, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - D J Ebler
- Division of Trauma Surgery and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, Education and Training International Medicine Institute, Miller School of Medicine, University of Miami, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - F N Mazzini
- Division of Trauma Surgery and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, Education and Training International Medicine Institute, Miller School of Medicine, University of Miami, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - P Petrone
- Division of Trauma Surgery and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, Education and Training International Medicine Institute, Miller School of Medicine, University of Miami, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - Juan A Asensio-Gonzalez
- Division of Trauma Surgery and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, Education and Training International Medicine Institute, Miller School of Medicine, University of Miami, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA. .,Westchester University Medical Center, New York Medical College, Trauma Department of Surgery, 100 Woods Road Taylor Pavilion, Suite E137, Valhalla, NY, 10595, USA.
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38
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Kauvar DS, Sarfati MR, Kraiss LW. National trauma databank analysis of mortality and limb loss in isolated lower extremity vascular trauma. J Vasc Surg 2011; 53:1598-603. [DOI: 10.1016/j.jvs.2011.01.056] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2010] [Revised: 01/14/2011] [Accepted: 01/22/2011] [Indexed: 11/26/2022]
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Kao MC, Jan WC, Tsai PS, Wang TY, Huang CJ. Magnesium sulfate mitigates lung injury induced by bilateral lower limb ischemia-reperfusion in rats. J Surg Res 2011; 171:e97-106. [PMID: 21514604 DOI: 10.1016/j.jss.2011.03.028] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Revised: 03/06/2011] [Accepted: 03/10/2011] [Indexed: 12/20/2022]
Abstract
BACKGROUND Lower limb ischemia-reperfusion (I/R) elicits oxidative stress and causes inflammation in lung tissues that may lead to lung injury. Magnesium sulfate (MgSO(4)) possesses potent anti-oxidation and anti-inflammation capacity. We sought to elucidate whether MgSO(4) could mitigate I/R-induced lung injury. As MgSO(4) is an L-type calcium channel inhibitor, the role of the L-type calcium channels was elucidated. MATERIALS AND METHODS Adult male rats were allocated to receive I/R, I/R plus MgSO(4) (10, 50, or 100 mg/kg), or I/R plus MgSO(4) (100 mg/kg) plus the L-type calcium channels activator BAY-K8644 (20 μg/kg) (n = 12 in each group). Control groups were run simultaneously. I/R was induced by applying rubber band tourniquets high around each thigh for 3 h followed by reperfusion for 3 h. After euthanization, degrees of lung injury, oxidative stress, and inflammation were determined. RESULTS Arterial blood gas and histologic assays, including histopathology, leukocyte infiltration (polymorphonuclear leukocytes/alveoli ratio and myeloperoxidase activity), and lung water content, confirmed that I/R caused significant lung injury. Significant increases in inflammatory molecules (chemokine, cytokine, and prostaglandin E(2) concentrations) and lipid peroxidation (malondialdehyde concentration) confirmed that I/R caused significant inflammation and oxidative stress in rat lungs. MgSO(4), at the dosages of 50 and 100 mg/kg but not 10 mg/kg, attenuated the oxidative stress, inflammation, and lung injury induced by I/R. Moreover, BAY-K8644 reversed the protective effects of MgSO(4). CONCLUSIONS MgSO(4) mitigates lung injury induced by bilateral lower limb I/R in rats. The mechanisms may involve inhibiting the L-type calcium channels.
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Affiliation(s)
- Ming-Chang Kao
- Department of Anesthesiology, Buddhist Tzu Chi General Hospital, Taipei Branch, Taipei, Taiwan
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40
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Peskun CJ, Levy BA, Fanelli GC, Stannard JP, Stuart MJ, MacDonald PB, Marx RG, Boyd JL, Whelan DB. Diagnosis and management of knee dislocations. PHYSICIAN SPORTSMED 2010; 38:101-11. [PMID: 21150149 DOI: 10.3810/psm.2010.12.1832] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
An acute knee dislocation is an uncommon injury, with a high rate of associated vascular and neurologic injuries as well as potentially limb-threatening complications. High-energy trauma is the most common cause of an acute knee dislocation, although lower-energy injuries, such as those sustained during athletic competition, are increasing in incidence. Injuries to the popliteal artery and common peroneal nerve are relatively common, requiring a high index of suspicion and complete neurovascular examination in a timely fashion. All cases of suspected knee dislocation should have an ankle-brachial index performed, reserving arteriography for those with an abnormal finding. Initial management consists of closed reduction, if possible, and application of a hinged brace or external fixator. Definitive management remains an area of controversy, although anatomic surgical repair or reconstruction is favored by most surgeons to help optimize knee function. Most patients treated for a knee dislocation can expect to return to their daily activities, but with less predictable returns to sporting activities.
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Peng TC, Jan WC, Tsai PS, Huang CJ. Heme oxygenase-1 mediates the protective effects of ischemic preconditioning on mitigating lung injury induced by lower limb ischemia-reperfusion in rats. J Surg Res 2010; 167:e245-53. [PMID: 20850789 DOI: 10.1016/j.jss.2010.06.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Revised: 05/14/2010] [Accepted: 06/04/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Lower limb ischemia-reperfusion (I/R) imposes oxidative stress, elicits inflammatory response, and subsequently induces acute lung injury. Ischemic preconditioning (IP), a process of transient I/R, mitigates the acute lung injury induced by I/R. We sought to elucidate whether the protective effects of IP involve heme oxygenase-1 (HO-1). METHODS Adult male rats were randomized to receive I/R, I/R plus IP, I/R plus IP plus the HO-1 inhibitor tin protoporphyrin (SnPP) (n = 12 in each group). Control groups were run simultaneously. I/R was induced by applying rubber band tourniquet high around each thigh for 3 h followed by reperfusion for 3 h. To achieve IP, three cycles of bilateral lower limb I/R (i.e., ischemia for 10 min followed by reperfusion for 10 min) were performed. IP was performed immediately before I/R. After sacrifice, degree of lung injury was determined. RESULTS Histologic findings, together with assays of leukocyte infiltration (polymorphonuclear leukocytes/alveoli ratio and myeloperoxidase activity) and lung water content (wet/dry weight ratio), confirmed that I/R induced acute lung injury. I/R also caused significant inflammatory response (increases in chemokine, cytokine, and prostaglandin E(2) concentrations), imposed significant oxidative stress (increases in nitric oxide and malondialdehyde concentrations), and up-regulated HO-1 expression in lung tissues. IP significantly enhanced HO-1 up-regulation and, in turn, mitigated oxidative stress, inflammatory response, and acute lung injury induced by I/R. In addition, the protective effects of IP were counteracted by SnPP. CONCLUSIONS The protective effects of IP on mitigating acute lung injury induced by lower limb I/R are mediated by HO-1.
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Affiliation(s)
- Tsui-Chin Peng
- Department of Anesthesiology, Buddhist Tzu Chi General Hospital, Taipei Branch, Taipei, Taiwan
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Hsu KY, Tsai PS, Lee JJ, Wang TY, Huang CJ. Platonin mitigates acute lung injury induced by bilateral lower limb ischemia-reperfusion in rats. J Surg Res 2010; 167:e255-62. [PMID: 20472255 DOI: 10.1016/j.jss.2010.03.075] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2010] [Revised: 03/25/2010] [Accepted: 03/30/2010] [Indexed: 11/28/2022]
Abstract
BACKGROUND Oxidative stress and inflammatory response are crucial in mediating the development of acute lung injury induced by bilateral lower limb ischemia-reperfusion (I/R). Platonin, a potent antioxidant, possesses anti-inflammation capacity. We sought to elucidate whether platonin could mitigate acute lung injury induced by lower limb I/R. MATERIALS AND METHODS Forty-eight adult male rats were allocated to receive I/R, I/R plus platonin (100 μg/kg intravenous injection immediately after reperfusion), sham instrumentation, or sham instrumentation plus platonin (denoted as the I/R, I/R-platonin, Sham, or Sham-platonin group, respectively; n = 12 in each group). Bilateral hind limb I/R was induced by applying rubber band tourniquets high around each thigh for 3 h followed by reperfusion for 3 h. After sacrifice, the degree of lung injury was determined. RESULTS Histologic findings revealed moderate inflammation in lung tissues of the I/R group and mild inflammation in those of the I/R-platonin group. Total cell number and protein concentration in bronchoalveolar lavage fluid as well as the leukocyte infiltration and myeloperoxidase activity in lung tissues of the I/R group were significantly higher than those of the I/R-platonin group. The pulmonary concentrations of macrophage inflammatory protein-2, interleukin-6, and prostaglandin E(2) of the I/R group were significantly higher than those of the I/R-platonin group. Moreover, the plasma nitric oxide concentration as well as the nitric oxide and malondialdehyde concentrations in lung tissues of the I/R group were significantly higher than those of the I/R-platonin group. CONCLUSIONS Platonin mitigates acute lung injury induced by bilateral lower limb I/R in rats.
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Affiliation(s)
- Kuei-Yao Hsu
- Department of Anesthesiology, Buddhist Tzu Chi General Hospital, Taipei Branch, Taipei, Taiwan
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Time Course Study on the Use of Temporary Intravascular Shunts as a Damage Control Adjunct in a Superior Mesenteric Artery Injury Model. ACTA ACUST UNITED AC 2010; 68:409-14. [PMID: 19826313 DOI: 10.1097/ta.0b013e31819ea416] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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44
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Impact of Intraoperative Arteriography on Limb Salvage for Traumatic Popliteal Artery Injury. ACTA ACUST UNITED AC 2009; 67:252-7; discussion 257-8. [DOI: 10.1097/ta.0b013e31819ea796] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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45
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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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Bergsland J, Lingaas PS, Skulstad H, Hol PK, Halvorsen PS, Andersen R, Småstuen M, Lundblad R, Svennevig J, Andersen K, Fosse E. Intracoronary Shunt Prevents Ischemia in Off-Pump Coronary Artery Bypass Surgery. Ann Thorac Surg 2009; 87:54-60. [PMID: 19101268 DOI: 10.1016/j.athoracsur.2008.08.032] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2008] [Revised: 08/12/2008] [Accepted: 08/13/2008] [Indexed: 10/21/2022]
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A decade's experience with temporary intravascular shunts at a civilian level I trauma center. ACTA ACUST UNITED AC 2008; 65:316-24; discussion 324-6. [PMID: 18695465 DOI: 10.1097/ta.0b013e31817e5132] [Citation(s) in RCA: 101] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND A 10-year review of temporary intravascular shunts (TIVS) at a regional trauma center. METHODS Retrospective chart review of all patients treated with temporary intravascular shunts from January 1, 1997 to January 1, 2007. RESULTS Seven hundred eighty-six patients were treated for vascular injuries. Sixty-seven (9%) had a total of 101 (72 arterial, 29 venous) TIVS placed to facilitate damage control or to allow for reconstruction of Gustilo IIIc fractures or limb replantation. Seven patients who, on trauma day 0, died or had an extremity which was deemed unsalvageable were excluded. Of 60 patients who met inclusion criteria, seven died from TBI (3%), MOF (3%), sepsis (2%), deceleration of care (2%), and loss of airway (2%), which was deemed preventable. CONCLUSIONS TIVS have a shunt thrombosis rate of 5%, amputation rate of 18%, overall survival of 88%, and combination limb/patient survival rate of 73%. TIVS have an established role primarily in patients requiring either "damage control" for exsanguination or temporary vascular conduits during stabilization of Gustilo IIIc fractures. Truncal injuries are associated with the highest mortality likely due to accompanying multisystem trauma.
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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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Woodward EB, Clouse WD, Eliason JL, Peck MA, Bowser AN, Cox MW, Jones WT, Rasmussen TE. Penetrating femoropopliteal injury during modern warfare: Experience of the Balad Vascular Registry. J Vasc Surg 2008; 47:1259-64; discussion 1264-5. [DOI: 10.1016/j.jvs.2008.01.052] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2007] [Revised: 01/24/2008] [Accepted: 01/25/2008] [Indexed: 10/22/2022]
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