1
|
Moody N, Walter A, Daudu D, Wahlgren CM, Jongkind V. International Perspective on Extremity Vascular Trauma in Children: A Scoping Review. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00200-4. [PMID: 38428670 DOI: 10.1016/j.ejvs.2024.02.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 02/17/2024] [Accepted: 02/26/2024] [Indexed: 03/03/2024]
Abstract
OBJECTIVE Extremity vascular trauma in children can result in significant morbidity and mortality. Most published studies have focused on supracondylar humeral fracture related injuries, with little focus on other injuries. This scoping review describes the current state of knowledge on paediatric vascular injuries in the upper and lower limbs, excluding injuries related to supracondylar humeral fractures. METHODS MEDLINE, PubMed, Web of Science, and Cochrane databases were searched for relevant studies evaluating the epidemiology, diagnosis, management, and outcomes of upper and lower limb vascular trauma in those aged under 18 years. Studies related to supracondylar humeral fractures were excluded. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for Scoping Reviews was used. RESULTS A total of 39 studies was included, all of which were retrospective, and 74% of which were based in North America or Europe. Extremity vascular trauma was reported to cause 0.6 - 4.4% of all paediatric trauma admissions, with penetrating mechanisms and upper limb injuries being the most common. Operative intervention was reported in 80 - 100% of children in the included studies. Primary repair was the most commonly reported operative intervention, followed by interposition graft and bypass graft. Synthetic graft use was less commonly reported (incidence range 0.5 - 33%). Lower limb fasciotomies and amputations were not commonly reported (incidence range 0 - 23% and 0 - 13%, respectively). The mortality rate appeared low, with 23 studies reporting no deaths (incidence range 0 - 4%). Complications were reported inconsistently, with no uniform outcome or follow up measures used. CONCLUSION The incidence of extremity vascular trauma appears low in children, with penetrating mechanisms and upper extremity injuries appearing to dominate. Most studies are from high income countries, with probable selection bias towards those treated by operative intervention. Prospective studies are required focusing on patterns of injury, rates of operative and endovascular intervention, and long term outcomes.
Collapse
Affiliation(s)
- N Moody
- Queen Elizabeth University Hospital, Glasgow, UK.
| | - A Walter
- Queen Elizabeth University Hospital, Glasgow, UK
| | - Davina Daudu
- Department of Surgery, University of Western Australia, Perth, Australia
| | - Carl-Magnus Wahlgren
- Department of Vascular Surgery, Karolinska University Hospital/Karolinska Institute, Stockholm, Sweden
| | - Vincent Jongkind
- Department of Surgery, Amsterdam UMC location Vrije Universiteit, Amsterdam, the Netherlands; Microcirculation - Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| |
Collapse
|
2
|
Johannesdottir BK, Geisner T, Gubberud ET, Gudbjartsson T. Civilian vascular trauma, treatment and outcome at a level 1-trauma centre. Scand J Trauma Resusc Emerg Med 2022; 30:74. [PMID: 36544205 PMCID: PMC9773450 DOI: 10.1186/s13049-022-01059-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 11/30/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Outcomes after vascular injuries in wartime are well documented, but studies on vascular injuries in a civilian European populations are scarce. METHODS A retrospective study on all adults admitted to a North-European level 1-trauma centre 2009-2018 with The Abbreviated Injury Scale-codes for non-iatrogenic vascular trauma (VT). Data were extracted from both national and regional trauma-registries, as well as patient charts. Patient demographics, mechanism, and location of vascular injury were registered as well as its treatment. Incidence and injury scores (ISS, NISS and TRISS) were calculated and overall survival (Kaplan-Meier) estimated. RESULTS Of 4042 trauma-patients, 68 (1.7%) (median age 44 years, 76% males) sustained 81 vascular injuries (69 arterial; 12 venous); 46 blunt and 22 (32%) penetrating injuries. The total incidence of vascular injuries was 1.45/100,000 inhabitants and did not change over the study-period (95% confidence interval 1.13-1.82). The injuries were located in thorax (n = 17), neck (n = 16) and abdominal region (n = 15); most of the blunt injuries followed traffic (n = 31) or falling accidents (n = 10), and with 17 of the 22 penetrating injuries due to stabbing. The median ISS and NISS-scores were 22 and 33, with 50 (74%) and 55 (81%) patients having scores > 15, respectively. Forty-three (63%) patients had open surgical repair and 8 (12%) received endovascular treatment. Twenty-one patients died within 30-days (31%), 33% and 27% after blunt and penetrating injuries, respectively. Half of the patients that died within 24 h sustained aortic injury. CONCLUSIONS Traumatic vascular injuries are rare in civilian settings and are less than 2% of major trauma admissions. These patients are often seriously injured and their treatment can be challenging with high 30-day mortality. TRIAL REGISTRATION Retrospectively registered.
Collapse
Affiliation(s)
- B. K. Johannesdottir
- grid.412008.f0000 0000 9753 1393Department of Vascular Surgery, Haukeland University Hospital, Jonas Lies vei 65, P.O. Box 1400, 5021 Bergen, Norway ,grid.14013.370000 0004 0640 0021Faculty of Medicine, University of Iceland, Reykjavík, Iceland
| | - T. Geisner
- grid.412008.f0000 0000 9753 1393Western Norway Trauma Centre, Haukeland University Hospital, Bergen, Norway
| | - E. T. Gubberud
- grid.412008.f0000 0000 9753 1393Department of Vascular Surgery, Haukeland University Hospital, Jonas Lies vei 65, P.O. Box 1400, 5021 Bergen, Norway
| | - T. Gudbjartsson
- grid.410540.40000 0000 9894 0842Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavík, Iceland ,grid.14013.370000 0004 0640 0021Faculty of Medicine, University of Iceland, Reykjavík, Iceland
| |
Collapse
|
3
|
Ortiz C, Vela J, Contreras C, Belmar F, Paul I, Zinco A, Ramos JP, Ottolino P, Achurra P, Jarufe N, Alseidi A, Varas J. A new approach for the acquisition of trauma surgical skills: an OSCE type of simulation training program. Surg Endosc 2022; 36:8441-8450. [PMID: 35237901 PMCID: PMC8890468 DOI: 10.1007/s00464-022-09098-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 02/07/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Worldwide, trauma-related deaths are one of the main causes of mortality. Appropriate surgical treatment is crucial to prevent mortality, however, in the past decade, general surgery residents' exposure to trauma cases has decreased, particularly since the COVID-19 pandemic. In this context, accessible simulation-based training scenarios are essential. METHODS A low-cost, previously tested OSCE scenario for the evaluation of surgical skills in trauma was implemented as part of a short training boot camp for residents and recently graduated surgeons. The following stations were included bowel anastomosis, vascular anastomosis, penetrating lung injury, penetrating cardiac injury, and gastric perforation (laparoscopic suturing). A total of 75 participants from 15 different programs were recruited. Each station was videotaped in high definition and assessed in a remote and asynchronous manner. The level of competency was assessed through global and specific rating scales alongside procedural times. Self-confidence to perform the procedure as the leading surgeon was evaluated before and after training. RESULTS Statistically significant differences were found in pre-training scores between groups for all stations. The lowest scores were obtained in the cardiac and lung injury stations. After training, participants significantly increased their level of competence in both grading systems. Procedural times for the pulmonary tractotomy, bowel anastomosis, and vascular anastomosis stations increased after training. A significant improvement in self-confidence was shown in all stations. CONCLUSION An OSCE scenario for training surgical skills in trauma was effective in improving proficiency level and self-confidence. Low pre-training scores and level of confidence in the cardiac and lung injury stations represent a deficit in residency programs that should be addressed. The incorporation of simulation-based teaching tools at early stages in residency would be beneficial when future surgeons face extremely severe trauma scenarios.
Collapse
Affiliation(s)
- Catalina Ortiz
- Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
- Experimental Surgery and Simulation Center, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Javier Vela
- Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
- Experimental Surgery and Simulation Center, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Caterina Contreras
- Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
- Experimental Surgery and Simulation Center, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Francisca Belmar
- Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
- Experimental Surgery and Simulation Center, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Ivan Paul
- Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
- Experimental Surgery and Simulation Center, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Analia Zinco
- Trauma Surgery Department, Hospital Sótero del Río, Santiago, Chile
| | - Juan Pablo Ramos
- Trauma Surgery Department, Hospital Sótero del Río, Santiago, Chile
| | - Pablo Ottolino
- Experimental Surgery and Simulation Center, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
- Trauma Surgery Department, Hospital Sótero del Río, Santiago, Chile
| | - Pablo Achurra
- Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
- Experimental Surgery and Simulation Center, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Nicolas Jarufe
- Department of Surgery, Clínica Las Condes, Santiago, Chile
| | - Adnan Alseidi
- Department of Surgery, University of California San Francisco, San Francisco, USA
| | - Julian Varas
- Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile.
- Experimental Surgery and Simulation Center, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile.
| |
Collapse
|
4
|
Parra MW, Ordoñez CA, Pino LF, Millán M, Caicedo Y, Buchelli VR, García A, González-Hadad A, Salcedo A, Serna JJ, Quintero L, Herrera MA, Hernández F, Rodríguez-Holguín F. Damage control surgery for thoracic outlet vascular injuries: the new resuscitative median sternotomy plus REBOA. Colomb Med (Cali) 2021; 52:e4054611. [PMID: 34908619 PMCID: PMC8634276 DOI: 10.25100/cm.v52i2.4611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 04/21/2021] [Accepted: 06/07/2021] [Indexed: 12/02/2022] Open
Abstract
Thoracic vascular trauma is associated with high mortality and is the second most common cause of death in patients with trauma following head injuries. Less than 25% of patients with a thoracic vascular injury arrive alive to the hospital and more than 50% die within the first 24 hours. Thoracic trauma with the involvement of the great vessels is a surgical challenge due to the complex and restricted anatomy of these structures and its association with adjacent organ damage. This article aims to delineate the experience obtained in the surgical management of thoracic vascular injuries via the creation of a practical algorithm that includes basic principles of damage control surgery. We have been able to show that the early application of a resuscitative median sternotomy together with a zone 1 resuscitative endovascular balloon occlusion of the aorta (REBOA) in hemodynamically unstable patients with thoracic outlet vascular injuries improves survival by providing rapid stabilization of central aortic pressure and serving as a bridge to hemorrhage control. Damage control surgery principles should also be implemented when indicated, followed by definitive repair once the correction of the lethal diamond has been achieved. To this end, we have developed a six-step management algorithm that illustrates the surgical care of patients with thoracic outlet vascular injuries according to the American Association of the Surgery of Trauma (AAST) classification.
Collapse
Affiliation(s)
- Michael W Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale, FL - USA
| | - Carlos A Ordoñez
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Luis Fernando Pino
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Mauricio Millán
- Universidad Icesi, Cali, Colombia.,Fundación Valle del Lili, Department of Surgery, Division of Transplant Surgery, Cali, Colombia
| | - Yaset Caicedo
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | | | - Alberto García
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Adolfo González-Hadad
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Centro Médico Imbanaco, Cali, Colombia
| | - Alexander Salcedo
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - José Julián Serna
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Laureano Quintero
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Centro Médico Imbanaco, Cali, Colombia
| | - Mario Alain Herrera
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Fabian Hernández
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Fernando Rodríguez-Holguín
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| |
Collapse
|
5
|
Choi K, Keum MA, Kim MS, Kim Y, Choi S, Kyoung KH, Kim JT, Kim S, Noh M. Feasibility of the Ultrasound-Guided Insertion of the Peripherally Inserted Central Catheter (PICC) by the Vascular Surgeon at the Bedside in the Trauma Intensive Care Unit. Ann Vasc Surg 2021; 80:143-151. [PMID: 34688877 DOI: 10.1016/j.avsg.2021.08.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 08/06/2021] [Accepted: 08/09/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND This study analyzed the outcomes of the ultrasound-guided insertion of the peripherally inserted central venous catheter (PICC) by experienced vascular surgeons at the bedside of the trauma intensive care unit (ICU) and compared the outcomes with those of fluoroscopy-guided PICC performed by radiologists in the interventional suite. METHODS Between May 1, 2016, and April 30, 2021, 97 patients who were hospitalized in the trauma ICU and underwent PICC insertion were enrolled in the study. Forty-two out of the 97 patients underwent PICC insertion by interventional radiologists in the interventional radiology suite under fluoroscopy guidance, while the remaining 55 cases underwent ultrasound-guided PICC insertion by the vascular surgeon at the trauma ICU bedside. RESULTS The technical failure (P = 0.504) and malposition (P = 0.127) rates were not significantly different between the 2 groups. However, it took significantly less time for the vascular surgeon to complete the PICC insertion procedure (P < 0.001). Significantly more patients of the ultrasound-guided group required inotropes (P = 0.012) and mechanical ventilation (P = 0.003) at the time of the procedure. In addition, the ultrasound-guided group appeared to be in critical condition in terms of kidney function according to laboratory data (P = 0.014). Meanwhile, the ultrasound-guided group maintained the central line catheter for a shorter time (P < 0.001). CONCLUSIONS In trauma patients, ultrasound-guided PICC insertion at the bedside by experienced vascular surgeons at the trauma ICU was feasible compared to fluoroscopy-guided insertion performed by interventional radiologists.
Collapse
Affiliation(s)
- Kyunghak Choi
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Min Ae Keum
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Min Soo Kim
- Department of Neurosurgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Youngwoong Kim
- Department of Thoracic and Cardiovascular Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Seongho Choi
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Kyu-Hyouck Kyoung
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Jihoon T Kim
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Sungjeep Kim
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Minsu Noh
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea.
| |
Collapse
|
6
|
Vela J, Cárcamo L, Contreras C, Arenas C, Ramos JP, Rebolledo R, Varas J, Martínez J, Jarufe N, Achurra P. SELF-CONFIDENCE ON ACQUIRED SURGICAL SKILLS TO DEAL WITH SEVERE TRAUMA PATIENTS IN RECENTLY GRADUATED SURGEONS. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2021; 34:e1561. [PMID: 34008705 PMCID: PMC8121062 DOI: 10.1590/0102-672020210001e1561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 09/18/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Level of competence by procedure. Trauma is one of the leading causes of death in the world and proper surgical care is critical to impact mortality. In Chile, trauma associated death ranks first as mortality cause in population between 20 and 59 years old. Appropriate surgical skills are required to deal with these complex patients. Self-confidence to practice trauma procedures after the General Surgery Residency have not been reported in our country. AIM Describe the level of self-confidence to deal with trauma procedures of surgeons who recently graduated from a General Surgery Residency. METHOD Descriptive cross-sectional study. We designed and applied a survey in 2015, 2016 and 2017 to recently graduated surgeons, to inquire about self-confidence of surgical skills to deal with trauma scenarios. Eighteen trauma surgery procedures (including cervical, thoracic, abdominal and vascular procedures) were evaluated using a 5-grade Likert scale. The number of procedures performed during the residency was also queried. RESULTS Eighty-eight recently graduated surgeons from 11 different training programs in Chile were included. The report of competencies was high in procedures such as intestinal injuries, were 98% felt competent or very competent in their repair. On the other hand, in complex traumas such as major vessel injury, up to 76% reported not being competent. Self-confidence on procedures was directly associated with the number of procedures performed during residency. CONCLUSIONS Recently graduated surgeons from General Surgery Programs report high levels of confidence to deal with low and intermediate complexity traumas, but a lower level of confidence to treat high complexity cases.
Collapse
Affiliation(s)
- Javier Vela
- Pontificia Universidad Católica de Chile, Digestive Surgery, Santiago, Región Metropolitana, Chile
- Pontificia Universidad Católica de Chile, Simulation and Experimental Surgery Center, Santiago, Región Metropolitana, Chile
| | - Leonardo Cárcamo
- Pontificia Universidad Católica de Chile, Digestive Surgery, Santiago, Región Metropolitana, Chile
| | - Caterina Contreras
- Pontificia Universidad Católica de Chile, Digestive Surgery, Santiago, Región Metropolitana, Chile
- Pontificia Universidad Católica de Chile, Simulation and Experimental Surgery Center, Santiago, Región Metropolitana, Chile
| | - Claudia Arenas
- Complejo Asistencial Dr. Sótero del Río, Unidad de Trauma y Urgencias, Santiago, Región Metropolitana, Chile
| | - Juan Pablo Ramos
- Complejo Asistencial Dr. Sótero del Río, Unidad de Trauma y Urgencias, Santiago, Región Metropolitana, Chile
| | - Rolando Rebolledo
- Pontificia Universidad Católica de Chile, Digestive Surgery, Santiago, Región Metropolitana, Chile
- Complejo Asistencial Dr. Sótero del Río, Unidad de Trauma y Urgencias, Santiago, Región Metropolitana, Chile
- Pontificia Universidad Católica de Chile, Intituto de Ingenería Biológica y Médica, Santiago, Región Metropolitana, Chile
| | - Julián Varas
- Pontificia Universidad Católica de Chile, Digestive Surgery, Santiago, Región Metropolitana, Chile
- Pontificia Universidad Católica de Chile, Simulation and Experimental Surgery Center, Santiago, Región Metropolitana, Chile
- Complejo Asistencial Dr. Sótero del Río, Unidad de Trauma y Urgencias, Santiago, Región Metropolitana, Chile
| | - Jorge Martínez
- Pontificia Universidad Católica de Chile, Digestive Surgery, Santiago, Región Metropolitana, Chile
| | - Nicolas Jarufe
- Pontificia Universidad Católica de Chile, Simulation and Experimental Surgery Center, Santiago, Región Metropolitana, Chile
| | - Pablo Achurra
- Pontificia Universidad Católica de Chile, Digestive Surgery, Santiago, Región Metropolitana, Chile
- Pontificia Universidad Católica de Chile, Simulation and Experimental Surgery Center, Santiago, Región Metropolitana, Chile
- Complejo Asistencial Dr. Sótero del Río, Unidad de Trauma y Urgencias, Santiago, Región Metropolitana, Chile
| |
Collapse
|
7
|
American Association for the Surgery of Trauma-World Society of Emergency Surgery guidelines on diagnosis and management of peripheral vascular injuries. J Trauma Acute Care Surg 2021; 89:1183-1196. [PMID: 33230048 DOI: 10.1097/ta.0000000000002967] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The peripheral arteries and veins of the extremities are among the most commonly injured vessels in both civilian and military vascular trauma. Blunt causes are more frequent than penetrating except during military conflicts and in certain geographic areas. Physical examination and simple bedside investigations of pulse pressures are key in early identification of these injuries. In stable patients with equivocal physical examinations, computed tomography angiograms have become the mainstay of screening and diagnosis. Immediate open surgical repair remains the first-line therapy in most patients. However, advances in endovascular therapies and more widespread availability of this technology have resulted in an increase in the range of injuries and frequency of utilization of minimally invasive treatments for vascular injuries in stable patients. Prevention of and early detection and treatment of compartment syndrome remain essential in the recovery of patients with significant peripheral vascular injuries. The decision to perform amputation in patients with mangled extremities remains difficult with few clear indicators. The American Association for the Surgery of Trauma in conjunction with the World Society of Emergency Surgery seeks to summarize the literature to date and provide guidelines on the presentation, diagnosis, and treatment of peripheral vascular injuries. LEVEL OF EVIDENCE: Review study, level IV.
Collapse
|
8
|
Johannesdottir BK, Johannesdottir U, Jonsson T, Lund SH, Mogensen B, Gudbjartsson T. High Mortality from Major Vascular Trauma in Traffic Accidents: A Population-Based Study. Scand J Surg 2019; 109:328-335. [PMID: 31354052 DOI: 10.1177/1457496919863944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIMS Injuries involving major arteries are an important cause of mortality and morbidity, most often from road traffic accidents. Our aim was to study the outcome of major vascular trauma from traffic accidents in an entire population, including patients who die at the scene and those who reach hospital alive. MATERIALS AND METHODS This was a retrospective analysis of all patients who sustained major vascular trauma in traffic accidents in Iceland from 2000 to 2011. Patient demographics, mechanism, and location of vascular injury and treatment were registered. Injury scores were calculated and overall survival estimated. RESULTS There were 62 individuals (mean age 44 years, 79% males) with 95 major vascular traumas, giving an incidence of 1.69/100,000 inhabitants (95% confidence interval: 1.27-2.21). A total of 33 died at the scene and 8 during transportation to hospital but 21 (34%) reached hospital alive. Most patients who succumbed had thoracic major vascular traumas (76%) or abdominal major vascular traumas (23%). Mean new injury severity score for the 21 admitted patients was 44. A total of 18 were operated with vascular repair, 3 with endovascular stent graft insertion. The mean hospital stay for discharged patients was 34 days. Altogether, 15 of the 62 patients (24%) survived to discharge from hospital, with a 5-year survival of 86% for discharged patients. CONCLUSION Every other patient with major vascular trauma following traffic accidents died at the scene and a further 13% died during transportation to hospital, most of whom sustained major vascular trauma to the thoracic aorta. However, one-third of the patients reached hospital alive and 71% of them survived to discharge, with excellent long-term survival.
Collapse
Affiliation(s)
- B K Johannesdottir
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland
| | - U Johannesdottir
- Department of Anaesthesia and Intensive Care Medicine, Landspitali University Hospital, Reykjavik, Iceland
| | - T Jonsson
- Department of Iceland National Blood Bank, Landspitali University Hospital, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - S H Lund
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - B Mogensen
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Emergency Medicine, Landspitali University Hospital, Reykjavik, Iceland
| | - T Gudbjartsson
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| |
Collapse
|
9
|
Xu Y, Xu W, Wang A, Meng H, Wang Y, Liu S, Li R, Lu S, Peng J. Diagnosis and treatment of traumatic vascular injury of limbs in military and emergency medicine: A systematic review. Medicine (Baltimore) 2019; 98:e15406. [PMID: 31045795 PMCID: PMC6504268 DOI: 10.1097/md.0000000000015406] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Traumatic vascular injury is caused by explosions and projectiles (bullets and shrapnel); it may affect the arteries and veins of the limbs, and is common in wartime, triggering bleeding, and ischemia. The increasing use of high-energy weapons in modern warfare is associated with severe vascular injuries. METHODS To summarize the current evidence of diagnosis and treatment for traumatic vascular injury of limbs, for saving limbs and lives, and put forward some new insights, we comprehensively consulted literatures and analyzed progress in injury diagnosis and wound treatment, summarized the advanced treatments now available, especially in wartime, and explored the principal factors in play in an effort to optimize clinical outcomes. RESULTS Extremity vascular trauma poses several difficult dilemmas in diagnosis and treatment. The increasing use of high-energy weapons in modern warfare is associated with severe vascular injuries. Any delay in treatment may lead to loss of limbs or death. The development of diagnose and treat vascular injury of extremities are the clinical significance to the tip of military medicine, such as the use of fast, cheap, low invasive diagnostic methods, repairing severe vascular injury as soon as possible, using related technologies actively (fasciotomy, etc). CONCLUSION We point out the frontier of the diagnosis and treatment of traumatic vascular injury, also with a new model of wartime injury treatment in American (forward surgical teams and combat support hospitals), French military surgeons regarding management of war-related vascular wounds and Chinese military ("3 districts and 7 grades" model). Many issues remain to be resolved by further experience and investigation.
Collapse
|
10
|
Markovic MD, Cvetkovic SD, Koncar IB, Dragas MV, Markovic DM, Kukic BP, Kuzmanovic IB, Dimic AD, Sladojevic MM, Davidovic LB. Treatment of pediatric vascular injuries: the experience of a single non-pediatric referral center. INT ANGIOL 2019; 38:250-255. [PMID: 30994319 DOI: 10.23736/s0392-9590.19.04124-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Pediatric peripheral vascular trauma carries significant risk of complications including limb loss and long-term invalidity. Mechanisms and types of morphological lesions are very diverse. The objectives of this study are to present the experience of a single vascular center in the surgical approach to pediatric vascular injuries, and to analyze the main challenges related to this clinical entity. METHODS Over a period of 25 years, 17 pediatric peripheral vascular injuries were treated in our institution. Patient's age ranged between one day (newborn) and 15 years (mean: 10.7 years). There were five injuries of upper and 12 injuries of the lower extremity. Preoperative diagnosis was established by clinical examination (N.=4), ultrasonography (N.=1) and angiography (N.=12). Blunt trauma mainly caused arterial thrombosis while penetrating trauma caused arterial laceration or complete transection. Five patients had associated orthopedic injuries (29,4%). There were two posttraumatic pseudoaneurysms and two arterio-venous fistulas. RESULTS There was no perioperative mortality. Vascular reconstructions included arterial suture (N.=4), thrombectomy + patch angioplasty (N.=1), termino-terminal anastomosis (N.=3), venous anatomic bypass (N.=6), PTFE graft reconstruction (N.=2), and venous extra-anatomic reconstruction (N.=1). Two patients had associated venous injury demanding both arterial and venous reconstruction. In the only case of war trauma treatment ended with limb loss. Other reconstructions presented good early and long-term patency. CONCLUSIONS Pediatric vascular injuries are extremely challenging issues. Treatment includes broad spectrum of different types of vascular reconstructions. It should be performed by vascular surgeon trained in open vascular treatment or pediatric surgeon with significant experience in vascular surgery.
Collapse
Affiliation(s)
- Miroslav D Markovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia - .,Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia -
| | - Slobodan D Cvetkovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Igor B Koncar
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Marko V Dragas
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Dragan M Markovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Biljana P Kukic
- Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Ilija B Kuzmanovic
- Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Andreja D Dimic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Milos M Sladojevic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Lazar B Davidovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
| |
Collapse
|
11
|
Biagioni RB, Burihan MC, Nasser F, Biagioni LC, Ingrund JC. Endovascular treatment of penetrating arterial trauma with stent grafts. VASA 2018; 47:125-130. [DOI: 10.1024/0301-1526/a000672] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Abstract. Background: The endovascular management of arterial injuries has resulted in reduced operating time, blood loss, hospital mortality, lower incidence of sepsis, and decrease in mortality rates. For penetrating trauma, however, the benefits of endovascular therapy are questionable. Patients and methods: Data were obtained by retrospective analysis of electronic medical records. All patients with vascular trauma seeking care at our institution from January 2010 to December 2015 were reviewed. A total of 223 vascular trauma patients were enrolled. Of these, 18 patients (8 %) were treated with endovascular techniques. The data related to clinical presentation, patient characteristics, technical aspects of the treatment, and follow-up were analysed. Results: The mean patient age was 35.4 ± 17.8 years, 94 % were male. The mean injury severity score was 10.4 ± 2.5. The most commonly observed trauma mechanism was a gunshot in 10 cases (55 %), followed by lesions provoked by arterial catheter misplacement in five cases (27 %), and stab wounds in three cases (16.6 %). The main injury site was the subclavian artery, accounting for eight cases (44 %), followed by the superficial femoral artery and the tibiofibular trunk in two cases, respectively (18 %). The anterior tibial, fibular artery, axillary, common carotid, superior mesenteric, and profunda femoris were each affected once. Arteriovenous fistula was detected in nine cases (50 %), pseudoaneurysms in nine cases (50 %), and short occlusion in two cases (11 %). The mean follow-up duration was 753 days. The primary patency rate was 92.3 and 61.5 % after one and two years, respectively. The survival rate was 94.4 % after one and two years. Infection of the stents or limb amputations were not identified at follow-up. Conclusions: The endovascular treatment of penetrating arterial injuries with covered stents is feasible. However, the criteria used to choose the best method must be individualized. Keywords: Trauma, endovascular, stent graft, gunshot, stab wound
Collapse
|
12
|
Evans C, Chaplin T, Zelt D. Management of Major Vascular Injuries: Neck, Extremities, and Other Things that Bleed. Emerg Med Clin North Am 2017; 36:181-202. [PMID: 29132576 DOI: 10.1016/j.emc.2017.08.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Vascular injuries represent a significant burden of mortality and disability. Blunt injuries to the neck vessels can present with signs of stroke either immediately or in a delayed fashion. Most injuries are detected with computed tomography angiography and managed with either antiplatelet medications or anticoagulation. In contrast, patients with penetrating injuries to the neck vessels require airway management, hemorrhage control, and damage control resuscitation before surgical repair. The keys to diagnosis and management of peripheral vascular injury include early recognition of the injury; hemorrhage control with direct pressure, packing, or tourniquets; and urgent surgical consultation.
Collapse
Affiliation(s)
- Chris Evans
- Trauma Services, Department of Emergency Medicine, Kingston General Hospital, Queen's University, Kingston, Ontario K7L 2V7, Canada.
| | - Tim Chaplin
- Department of Emergency Medicine, Queen's University, Kingston, Ontario K7L 2V7, Canada
| | - David Zelt
- Division of Vascular Surgery, Kingston General Hospital, Queen's University, Kingston, Ontario K7L 2V7, Canada
| |
Collapse
|
13
|
Wang E, Inaba K, Cho J, Byerly S, Rowe V, Benjamin E, Lam L, Demetriades D. Do Antiplatelet and Anticoagulation Agents Matter after Repair of Traumatic Arterial Injuries? Am Surg 2016. [DOI: 10.1177/000313481608201024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Thrombosis is a devastating complication after repair of traumatic vascular injury. Although thrombosis rates have been described, the value of anticoagulation in preventing postrepair thrombosis is unknown. We hypothesize that postoperative anticoagulation reduces thrombosis rates. A total of 1524 consecutive patients with traumatic arterial injuries from January 2005 to June 2015 were identified, and 381 patients underwent the following repair types: direct suture of vessel wall, primary anastomosis, extra-anatomic reconstruction, tissue and synthetic interposition reconstruction. Twenty six patients received postoperative heparin at therapeutic levels, and 29 patients received postoperative aspirin for five consecutive days. The heparin and aspirin groups were matched with patients without postoperative anticoagulation by the following variables: anatomic arterial injury, type of vascular repair, and age. These groups were then compared using the following outcome measures: mortality, thrombosis of repaired vessel, amputation, hemorrhage, cerebral vascular accident, and extremity compartment syndrome. The demographics between the heparin, aspirin, and respectively matched groups were not statistically different. There was no statistically significant difference in the rate of thrombosis, bleeding, compartment syndrome, cerebral vascular accident, limb amputation, or mortality. Although there was no increase in bleeding complications with the use of heparin or aspirin, there was also no impact on the rate of thrombosis.
Collapse
Affiliation(s)
- Eugene Wang
- From the Division of Trauma and Critical Care, University of Southern California, Los Angeles, California
| | - Kenji Inaba
- From the Division of Trauma and Critical Care, University of Southern California, Los Angeles, California
| | - Jayun Cho
- From the Division of Trauma and Critical Care, University of Southern California, Los Angeles, California
| | - Saskya Byerly
- From the Division of Trauma and Critical Care, University of Southern California, Los Angeles, California
| | - Vincent Rowe
- From the Division of Trauma and Critical Care, University of Southern California, Los Angeles, California
| | - Elizabeth Benjamin
- From the Division of Trauma and Critical Care, University of Southern California, Los Angeles, California
| | - Lydia Lam
- From the Division of Trauma and Critical Care, University of Southern California, Los Angeles, California
| | - Demetrios Demetriades
- From the Division of Trauma and Critical Care, University of Southern California, Los Angeles, California
| |
Collapse
|
14
|
He JC, Clancy K, Schechtman D, Conrad-Schnetz KJ, Claridge JA. Traumatic vascular injuries: who are repairing them and what are the outcomes? Am J Surg 2016; 211:619-25. [DOI: 10.1016/j.amjsurg.2015.11.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 11/05/2015] [Accepted: 11/06/2015] [Indexed: 11/28/2022]
|
15
|
|
16
|
Abstract
Peripheral vascular injuries are the cause of high morbidity in trauma patients. Up to 5 % of all patients with injuries of the extremities present with concomitant vascular lesions. While open peripheral vascular injuries are associated with a high mortality at the scene of the accident, closed vascular injuries present the danger of developing critical tissue ischemia with a high risk of amputation and limb loss. Early diagnosis is crucial in order to rapidly restore and maintain adequate blood flow and downstream tissue perfusion. A correct diagnosis and early treatment of peripheral vascular injuries place enormous demands on interdisciplinary teams consisting of emergency physicians, orthopedic surgeons, vascular surgeons, anesthesiologists and radiologists. The top priority in the context of emergency care is hemorrhage control by applying direct pressure and dressings until definitive surgical treatment. Hypovolemic shock, reperfusion injury and compartment syndrome are complications of peripheral vascular injuries that must be recognized and treated in the early stages.
Collapse
|