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Falcon AK, Caballero LM, Filiberto DM, Lenart EK, Easterday TS, Bhatt MN, Mitchell EL, Byerly S. Risk Factors for Venous Thromboembolism and Eventual Amputation in Traumatic Femoral and Iliac Vein Injuries: A Trauma Quality Improvement Program Analysis. Am Surg 2024; 90:1879-1885. [PMID: 38527489 DOI: 10.1177/00031348241241645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
BACKGROUND Iliac and femoral venous injuries represent a challenging dilemma in trauma surgery with mixed results. Venous restoration of outflow (via repair or bypass) has been previously identified as having higher rates of VTE (venous thromboembolism) compared to ligation. We hypothesized that rates of VTE and eventual amputation were similar whether restoration of venous outflow vs ligation was performed at initial operation. METHODS Patients in the 2019-2021 National Trauma Data Bank with iliac and femoral vein injuries were abstracted and analyzed. The primary outcomes of interest were in-hospital lower extremity amputation and VTE. RESULTS A total of 2642 patients with operatively managed iliac and femoral vein injuries were identified VTE was found in 10.8% of patients. Multivariable logistic regression was performed and identified bowel injury, higher ISS, older age, open repair, and longer time to VTE prophylaxis initiation as independent predictors of VTE. Amputation was required in 4.2% of patients. Multivariable logistic regression identified arterial or nerve injury, femur or tibia fracture, venous ligation, percutaneous intervention, fasciotomy, bowel injury, and higher ISS as independent factors of amputation. CONCLUSION Venous restoration was not an independent predictor of VTE. Venous ligation on index operation was the only modifiable independent predictor of amputation identified on regression analysis.
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Affiliation(s)
- Allison K Falcon
- Department of Surgery, University of Tennessee Health Science Campus, Memphis, TN, USA
| | - Ladd M Caballero
- Department of Surgery, University of Tennessee Health Science Campus, Memphis, TN, USA
| | - Dina M Filiberto
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Tennessee Health Science Campus, Memphis, TN, USA
| | - Emily K Lenart
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Tennessee Health Science Campus, Memphis, TN, USA
| | - Thomas S Easterday
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Tennessee Health Science Campus, Memphis, TN, USA
| | - Maunil N Bhatt
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Tennessee Health Science Campus, Memphis, TN, USA
| | - Erica L Mitchell
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Tennessee Health Science Campus, Memphis, TN, USA
| | - Saskya Byerly
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Tennessee Health Science Campus, Memphis, TN, USA
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Lim C, Roh YH, Kim DW, Nam KW. Is the May-Thurner Syndrome a Major Risk Factor for Deep Vein Thrombosis in Total Hip Arthroplasty? Clin Orthop Surg 2024; 16:34-40. [PMID: 38304205 PMCID: PMC10825252 DOI: 10.4055/cios23128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 09/04/2023] [Accepted: 09/07/2023] [Indexed: 02/03/2024] Open
Abstract
Background May-Thurner syndrome (MTS) is iliac vein compression syndrome associated with postoperative deep vein thrombosis (DVT) resulting from chronic compression of the left iliac vein against lumbar vertebrae by the overlying right or left common iliac artery. MTS is not well known as a risk factor for DVT after total hip arthroplasty (THA). We evaluated the incidence of DVT after THA and analyzed if the MTS is a risk factor for DVT after THA. We hypothesized that MTS would be associated with an increased risk of developing DVT after THA. Methods All patients > 65 years of age who underwent THA between January 1, 2009, and January 12, 2017, were identified. Among them, the patients who presented for postoperative DVT of the lower extremity were reviewed with medical record data. MTS was diagnosed with computed tomography (CT) angiography of the lower extremity. We analyzed the demographic data, symptoms, diagnoses, and treatment of MTS patients. Results A total of 492 consecutive patients aged > 65 years who underwent operation for THA were enrolled. Among them, 5 patients (1.0%) presented for postoperative DVT of the lower extremity. After reviewing the CT angiography of the lower extremity, 4 out of 5 DVT patients (80%) were identified as having MTS. All MTS patients were female and presented with pain and swelling of the left leg. All MTS patients were treated with systemic anticoagulation, aspiration thrombectomy, and percutaneous transluminal angioplasty. Complete resolution of thrombus was observed in all patients. Conclusions If the diagnosis of MTS is delayed, the morbidity and mortality rates are significantly increased. Orthopedic surgeons should be aware of MTS as a risk factor for DVT after THA. Moreover, preoperative evaluation with duplex sonography or CT angiography to confirm MTS should be considered. In this regard, this study is considered to have sufficient clinical value for early diagnosis and appropriate treatment of MTS after THA.
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Affiliation(s)
- Chaemoon Lim
- Department of Orthopedic Surgery, Jeju National University Hospital, Jeju, Korea
| | - Young Ho Roh
- Department of Orthopedic Surgery, Jeju National University Hospital, Jeju, Korea
| | - Dae Whan Kim
- Department of Orthopedic Surgery, Jeju National University Hospital, Jeju, Korea
| | - Kwang Woo Nam
- Department of Orthopaedic Surgery, Uijeongbu Eulji Medical Center, Eulji University, Uijeongbu, Korea
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Melinte RM, Arbănași EM, Blesneac A, Zolog DN, Kaller R, Mureșan AV, Arbănași EM, Melinte IM, Niculescu R, Russu E. Inflammatory Biomarkers as Prognostic Factors of Acute Deep Vein Thrombosis Following the Total Knee Arthroplasty. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58101502. [PMID: 36295662 PMCID: PMC9608310 DOI: 10.3390/medicina58101502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 10/08/2022] [Accepted: 10/19/2022] [Indexed: 11/05/2022]
Abstract
Background and objectives: Deep vein thrombosis (DVT) is one of the most serious post-operative complications in the case of total knee arthroplasty (TKA). This study aims to verify the predictive role of inflammatory biomarkers [monocyte-to-lymphocyte ratio (MLR), neutrophil-to-lymphocyte ratio (NLR), platelets-to-lymphocyte ratio (PLR), systemic inflammatory index (SII), systemic inflammation response index (SIRI), and aggregate index of systemic inflammation (AISI)] in acute DVT following TKA. Materials and methods: The present study was designed as an observational, analytical, retrospective cohort study and included all patients over 18 years of age with surgical indications for TKA, admitted to the Department of Orthopedics, Regina Maria Health Network, Targu Mures, Romania, and the Department of Orthopedics, Humanitas MedLife Hospital, Cluj-Napoca, Romania between January 2017 and July 2022. The primary endpoint was the risk of acute DVT following the TKA, and the secondary endpoint was the length of hospital stay, and the outcomes were stratified for the baseline’s optimal MLR, NLR, PLR, SII, SIRI, and AISI cut-off value. Results: DVT patients were associated with higher age (p = 0.01), higher incidence of cardiac disease [arterial hypertension (p = 0.02), atrial fibrillation (p = 0.01)], malignancy (p = 0.005), as well as risk factors [smoking (p = 0.03) and obesity (p = 0.02)]. Multivariate analysis showed a high baseline value for all hematological ratios: MLR (OR: 11.06; p < 0.001), NLR (OR: 10.15; p < 0.001), PLR (OR: 12.31; p < 0.001), SII (OR: 18.87; p < 0.001), SIRI (OR: 10.86; p < 0.001), and AISI (OR: 14.05; p < 0.001) was an independent predictor of DVT after TKA for all recruited patients. Moreover, age above 70 (OR: 2.96; p = 0.007), AH (OR: 2.93; p = 0.02), AF (OR: 2.71; p = 0.01), malignancy (OR: 3.98; p = 0.002), obesity (OR: 2.34; p = 0.04), and tobacco (OR: 2.30; p = 0.04) were all independent predictors of DVT risk. Conclusions: Higher pre-operative hematological ratios MLR, NLR, PLR, SII, SIRI, and AISI values determined before operations strongly predict acute DVT following TKA. Moreover, age over 70, malignancy, cardiovascular disease, and risk factors such as obesity and tobacco were predictive risk factors for acute DVT.
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Affiliation(s)
- Răzvan Marian Melinte
- Department of Orthopedics, Regina Maria Health Network, 540098 Targu Mures, Romania
- Department of Orthopedics, Humanitas MedLife Hospital, 400664 Cluj Napoca, Romania
| | - Emil Marian Arbănași
- Clinic of Vascular Surgery, Mures County Emergency Hospital, 540136 Targu Mures, Romania
| | - Adrian Blesneac
- Department of Orthopedics, Regina Maria Health Network, 540098 Targu Mures, Romania
| | - Dan Nicolae Zolog
- Department of Orthopedics, Regina Maria Health Network, 540098 Targu Mures, Romania
| | - Réka Kaller
- Clinic of Vascular Surgery, Mures County Emergency Hospital, 540136 Targu Mures, Romania
| | - Adrian Vasile Mureșan
- Clinic of Vascular Surgery, Mures County Emergency Hospital, 540136 Targu Mures, Romania
- Department of Surgery, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540139 Targu Mures, Romania
- Correspondence:
| | - Eliza Mihaela Arbănași
- Faculty of Pharmacy, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540139 Targu Mures, Romania
| | - Ioana Marta Melinte
- Faculty of Medicine, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540139 Targu Mures, Romania
| | - Raluca Niculescu
- Department of Pathophysiology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540139 Targu Mures, Romania
| | - Eliza Russu
- Clinic of Vascular Surgery, Mures County Emergency Hospital, 540136 Targu Mures, Romania
- Department of Surgery, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540139 Targu Mures, Romania
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Hynes AM, Scantling DR, Murali S, Bormann BC, Paul JS, Reilly PM, Seamon MJ, Martin ND. What happens after they survive? The role of anticoagulants and antiplatelets in IVC injuries. Trauma Surg Acute Care Open 2022; 7:e000923. [PMID: 35813557 PMCID: PMC9214426 DOI: 10.1136/tsaco-2022-000923] [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: 03/15/2022] [Accepted: 05/20/2022] [Indexed: 11/07/2022] Open
Abstract
Background Venous thromboembolism (VTE) after an inferior vena cava (IVC) injury is a devastating complication. Current practice involves variable use of anticoagulation and antiplatelet (AC/AP) agents. We hypothesized that AC/AP can reduce the incidence of VTE and that delayed institution of AC/AP is associated with increased VTE events. Methods We retrospectively reviewed IVC injuries cared for at a large urban adult academic level 1 trauma center between January 1, 2008 and December 31, 2020, surviving 72 hours. Patient demographics, injury mechanism, surgical repair, type and timing of AC, and type and timing of VTE events were characterized. Postoperative AC status during hospital course before an acute VTE event was delineated by grouping patients into four categories: full, prophylactic, prophylactic with concomitant AP, and none. The primary outcome was the incidence of an acute VTE event. IVC ligation was excluded from analysis. Results Of the 76 patients sustaining an IVC injury, 26 were included. The incidence of a new deep vein thrombosis distal to the IVC injury and a new pulmonary embolism was 31% and 15%, respectively. The median onset of VTE was 5 days (IQR 1–11). Four received full AC, 10 received prophylactic AC with concomitant AP, 8 received prophylactic AC, and 4 received no AC/AP. New VTE events occurred in 0.0% of full, in 30.0% of prophylactic with concomitant AP, in 50.0% of prophylactic, and in 50.0% without AC/AP. There was no difference in baseline demographics, injury mechanisms, surgical interventions, and bleeding complications. Discussion This is the first study to suggest that delay and degree of antithrombotic initiation in an IVC-injured patient may be associated with an increase in VTE events. Consideration of therapy initiation should be performed on hemostatic stabilization. Future studies are necessary to characterize the optimal dosing and temporal timing of these therapies. Level of evidence Therapeutic, level 3.
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Affiliation(s)
- Allyson M Hynes
- Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
- Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Dane R Scantling
- Surgery, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Shyam Murali
- Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Jasmeet S Paul
- Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Patrick M Reilly
- Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mark J Seamon
- Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Niels D Martin
- Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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O'Shea AE, Lee C, Kauvar DS. Analysis of Concomitant and Isolated Venous Injury in Military Lower Extremity Trauma. Ann Vasc Surg 2022; 87:147-154. [PMID: 35460859 DOI: 10.1016/j.avsg.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 04/11/2022] [Accepted: 04/11/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVES The implications of major venous injury to the lower extremity are not well established. We aimed to determine the significance of concomitant and isolated femoropopliteal venous injury and assess the impact of surgical management strategies on limb outcomes. METHODS The Fasciotomy and Vascular Injury Outcomes Database was queried for limbs sustaining femoropopliteal arterial, venous, or concomitant injuries in Iraq or Afghanistan between 2004-2012. Demographics, injury patterns and severity, interventions, and outcomes were compared between patients sustaining isolated arterial injuries (IAI) and concomitant arteriovenous injuries (AVI). In limbs with any venous injury, outcomes were compared between those undergoing venous (VR) and ligation (VL). RESULTS 330 patients (133 IAI, 135 AVI, 62 isolated venous injuries (IVI)) were included. AVI was associated with greater limb injury severity: median extremity Abbreviated Injury Scale (AVI 4 vs. IAI 3, p=0.01), Mangled Extremity Severity Score >7 (25.9% vs. 13.5%, p= 0.01), multi-level vascular injury (6.7% vs. 0.8%, p=0.01) and with greater fasciotomy use (83.0% vs. 69.2%, p=0.01). No differences were present in tourniquet use/time, shunting, or nature of arterial repair. No differences in vascular or limb complications (71.1% vs. 63.9%, p=0.21) or amputation rate (25.9% vs. 18.8%, p=0.16) were present, though limb DVT rate was 12.6% in AVI vs. 7.5% in IAI (p=0.17). Limbs with IVI had a 12.9% amputation and a 74.2% complication rate. Repair (n=103) versus ligation (n=94) of venous injuries was not associated with a difference in amputation (18.4% vs. 25.5%, p=0.23) or limb complication rates (71.8% vs. 72.3%, p=0.94). CONCLUSION Despite higher extremity injury severity and more frequent fasciotomies, concomitant venous injury was not associated with poorer limb salvage or complications. With nontrivial amputation and complication rates, IVI is indicative of severe limb trauma. Repair of femoropopliteal venous injuries does not appear to influence limb outcomes.
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Affiliation(s)
- Anne E O'Shea
- Department of Surgery, Brooke Army Medical Center, Ft. Sam Houston, TX, USA
| | - Christina Lee
- Department of Surgery, Brooke Army Medical Center, Ft. Sam Houston, TX, USA
| | - David S Kauvar
- Vascular Surgery Service, Brooke Army Medical Center, Ft. Sam Houston, TX, USA; Department of Surgery, Uniformed Services University, Bethesda, MD, USA.
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Abstract
ABSTRACT This is a literature review on the history of venous trauma since the 1800s, especially that to the common femoral, femoral and popliteal veins, with focus on the early 1900s, World War I, World War II, Korean War, Vietnam War, and then civilian and military reviews (1960-2020). In the latter two groups, tables were used to summarize the following: incidence of venous repair versus ligation, management of popliteal venous injuries, patency of venous repairs when assessed <30 days from operation, patency of venous repairs when assessed >30 days from operation, clinical assessment (edema or not) after ligation versus repair, incidence of deep venous thrombosis after ligation versus repair, and incidence of pulmonary embolism after ligation versus repair.There is a lack of the following in the literature on the management of venous injuries over the past 80 years: standard definition of magnitude of venous injury in operative reports, accepted indications for venous repair, standard postoperative management, and timing and mode of early and later postoperative assessment.Multiple factors have entered into the decision on venous ligation versus repair after trauma for the past 60 years, but a surgeon's training and local management protocols have the most influence in both civilian and military centers. Ligation of venous injuries, particularly those in the lower extremities, is well tolerated in civilian trauma, although there is the usual lack of short- and long-term follow-up as noted in many of the articles reviewed. LEVEL OF EVIDENCE Review article, levels IV and V.
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Affiliation(s)
- David V Feliciano
- From the Department of Surgery (D.V.F.), Shock Trauma Center, University of Maryland Medical Center, University of Maryland, Baltimore, Maryland; Division of Acute Care Surgery, Department of Surgery (M.P.K.), University of Florida Health Jacksonville Medical Center, Jacksonville, Florida; and Division of Acute Care Surgery, Department of Surgery (G.F.R.), John Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Identification of genes, pathways and transcription factor-miRNA-target gene networks and experimental verification in venous thromboembolism. Sci Rep 2021; 11:16352. [PMID: 34381164 PMCID: PMC8357955 DOI: 10.1038/s41598-021-95909-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 08/02/2021] [Indexed: 12/17/2022] Open
Abstract
Venous thromboembolism (VTE) is a complex, multifactorial life-threatening disease that involves vascular endothelial cell (VEC) dysfunction. However, the exact pathogenesis and underlying mechanisms of VTE are not completely clear. The aim of this study was to identify the core genes and pathways in VECs that are involved in the development and progression of unprovoked VTE (uVTE). The microarray dataset GSE118259 was downloaded from the Gene Expression Omnibus database, and 341 up-regulated and 8 down-regulated genes were identified in the VTE patients relative to the healthy controls, including CREB1, HIF1α, CBL, ILK, ESM1 and the ribosomal protein family genes. The protein–protein interaction (PPI) network and the transcription factor (TF)-miRNA-target gene network were constructed with these differentially expressed genes (DEGs), and visualized using Cytoscape software 3.6.1. Eighty-nine miRNAs were predicted as the targeting miRNAs of the DEGs, and 197 TFs were predicted as regulators of these miRNAs. In addition, 237 node genes and 4 modules were identified in the PPI network. The significantly enriched pathways included metabolic, cell adhesion, cell proliferation and cellular response to growth factor stimulus pathways. CREB1 was a differentially expressed TF in the TF-miRNA-target gene network, which regulated six miRNA-target gene pairs. The up-regulation of ESM1, HIF1α and CREB1 was confirmed at the mRNA and protein level in the plasma of uVTE patients. Taken together, ESM1, HIF1α and the CREB1-miRNA-target genes axis play potential mechanistic roles in uVTE development.
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Haqqani MH, Levin SR, Kalish JA, Brahmbhatt TS, Richman AP, Siracuse JJ, Farber A, Jones DW. High Mortality and Venous Thromboembolism Risk Following Major Penetrating Abdominal Venous Injuries. Ann Vasc Surg 2021; 76:193-201. [PMID: 34153491 DOI: 10.1016/j.avsg.2021.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/31/2021] [Accepted: 06/09/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Penetrating injuries to the inferior vena cava and/or iliac veins are a source of hemorrhage but may also predispose patients to venous thromboembolism (VTE). We sought to determine the relationship between iliocaval injury, VTE and mortality. METHODS The National Trauma Data Bank was queried for penetrating abdominal trauma from 2015-2017. Univariate analyses compared baseline characteristics and outcomes based on presence of iliocaval injury. Multivariable analyses determined the effect of iliocaval injury on VTE and mortality. RESULTS Of 9,974 patients with penetrating abdominal trauma, 329 had iliocaval injury (3.3%). Iliocaval injury patients were more likely to have a firearm mechanism (83% vs. 43%, P < 0.001), concurrent head (P = 0.036), spinal cord (P < 0.001), and pelvic injuries (P < 0.001), and higher total injury severity score (median 20 vs. 8.0, P < 0.001). They were more likely to undergo 24-hr hemorrhage control surgery (69% vs. 17%, P < 0.001), but less likely to receive VTE chemoprophylaxis during admission (64% vs. 68%, P = 0.04). Of patients undergoing iliocaval surgery, 64% underwent repair, 26% ligation, and 10% unknown. Iliocaval injury patients had higher rates of VTE (12% vs. 2%), 24-hr mortality (23% vs. 2.0%) and in-hospital mortality (33% vs. 3.4%) (P < 0.001 for all). VTE rates were similar following repair (14%) and ligation (17%). Iliocaval injury patients also had higher rates of cardiac complications (10.3% vs. 1.4%), acute kidney injury (8.2% vs. 1.3%), extremity compartment syndrome (4.0 vs. 0.2%), and unplanned return to OR (7.9% vs. 2.5%) (P < 0.001 for all). In multivariable analyses, iliocaval injury was independently associated with risk of VTE (OR 2.12; 95% CI, 1.29-3.48; P = 0.003), and in-hospital mortality (OR = 9.61; 95% CI, 4.96-18.64; P < 0.001). CONCLUSION Iliocaval injuries occur in <5% of penetrating abdominal trauma but are associated with more severe injury patterns and high mortality rates. Regardless of repair type, survivors should be considered high risk for developing VTE.
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Affiliation(s)
- Maha H Haqqani
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Scott R Levin
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Jeffrey A Kalish
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Tejal S Brahmbhatt
- Division of Acute Care and Trauma Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Aaron P Richman
- Division of Acute Care and Trauma Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Alik Farber
- Division of Acute Care and Trauma Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Douglas W Jones
- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical Center, University of Massachusetts Medical School, Worcester, MA.
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Chang W, Wang B, Li Q, Zhang Y, Xie W. Study on the Risk Factors of Preoperative Deep Vein Thrombosis (DVT) in Patients With Lower Extremity Fracture. Clin Appl Thromb Hemost 2021; 27:10760296211002900. [PMID: 33754840 PMCID: PMC7995307 DOI: 10.1177/10760296211002900] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Objective: The objective of this work is to discuss and analyze the related factors of lower extremity fracture complicated by preoperative deep vein thrombosis (DVT). Methods: A total of 11,891 patients with closed fractures of lower extremities were selected. By analyzing each patient’s gender, age, presence or absence of diabetes and hypertension, preoperative plasma D-dimer level, and color Doppler ultrasound of the lower extremity vein, the pertinent factors of the patients with lower extremity fractures complicated by preoperative DVT were analyzed. Results: A total of 578 with preoperative DVT were detected, displaying a total incidence of 4.86%. All patients were categorized into either the DVT group or non-DVT group. The results demonstrate that there were statistically significant differences between the 2 groups in age, the presence of diabetes and hypertension, the fracture site, and the preoperative plasma D-dimer level (P < 0.05). Logistic multivariate analysis revealed that age, the presence of diabetes, and the preoperative plasma D-dimer level of patients were independent risk factors for lower extremity fracture complicated by DVT. Conclusion: Age, the presence of diabetes, the fracture site, and increased D-dimer levels were found to be potential risk factors and indicators for preoperative DVT in patients with lower extremity fractures. In addition, the preoperative plasma D-dimer level has certain guiding significance for the prediction of venous thrombosis after lower extremity fracture, which is conducive to the early prediction and diagnosis of DVT, but it often must be followed with good clinic acumen and examinations.
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Affiliation(s)
- Wenjie Chang
- 74738Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Bin Wang
- Laizhou Hospital of Traditional Chinese Medicine, Laizhou, China
| | - Qiwei Li
- 74738Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Yongkui Zhang
- Department of Orthopedic Surgery, 159393Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Lixia District, Jinan City, Shandong Province, China
| | - Wenpeng Xie
- Department of Orthopedic Surgery, 159393Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Lixia District, Jinan City, Shandong Province, China
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Farrell MS, Knudson MM, Stein DM. Venous ligation versus venous repair: does the procedure impact venous thromboembolism risk? Trauma Surg Acute Care Open 2021; 6:e000687. [PMID: 33791437 PMCID: PMC7978278 DOI: 10.1136/tsaco-2021-000687] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 02/22/2021] [Accepted: 02/28/2021] [Indexed: 12/14/2022] Open
Abstract
Background Traumatic lower extremity venous injuries are most commonly managed with either a vein ligation or repair procedure. Venous injuries are associated with an increased risk of developing venous thromboembolisms (VTE), but little is understood with regard to how specific surgical treatments may impact the risk of developing either a deep vein thrombosis (DVT) or a pulmonary embolism (PE). In this study of lower extremity venous injuries, we hypothesized that venous ligation would be associated with an increased risk of DVT but a lower risk of PE when compared with venous repair. Methods Patients were identified from the National Trauma Data Bank (2008 to 2014) with at least one iliac, femoral, popliteal, or tibial venous injury and who received either a vein ligation or repair. The patients were then compared based on the type of procedure and the location of the injury to assess the risk of DVT and PE between the groups. Results A total of 1214 patients were identified. There was no difference between patients who received a vein ligation versus a repair with respect to age, injury severity score, or initial systolic blood pressure. There was no difference in the odds of developing either a DVT or PE between patients who were treated with vein ligation versus repair. There was also no difference in VTE rates when stratified by the location of the injury. Conclusions In individuals with lower extremity venous injuries, there is no difference in the rate of DVT or PE complications when comparing venous repair and ligation procedures. The role of anticoagulation remains to be elucidated following operative treatment. Level of evidence Therapeutic/Care Management, Level IV.
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Affiliation(s)
- Michael Steven Farrell
- Surgery, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - M Margaret Knudson
- Surgery, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Deborah M Stein
- Surgery, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
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Santana DC, Emara AK, Orr MN, Klika AK, Higuera CA, Krebs VE, Molloy RM, Piuzzi NS. An Update on Venous Thromboembolism Rates and Prophylaxis in Hip and Knee Arthroplasty in 2020. MEDICINA (KAUNAS, LITHUANIA) 2020; 56:E416. [PMID: 32824931 PMCID: PMC7558636 DOI: 10.3390/medicina56090416] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 08/10/2020] [Accepted: 08/14/2020] [Indexed: 12/16/2022]
Abstract
Patients undergoing total hip and knee arthroplasty are at high risk for venous thromboembolism (VTE) with an incidence of approximately 0.6-1.5%. Given the high volume of these operations, with approximately one million performed annually in the U.S., the rate of VTE represents a large absolute number of patients. The rate of VTE after total hip arthroplasty has been stable over the past decade, although there has been a slight reduction in the rate of deep venous thrombosis (DVT), but not pulmonary embolism (PE), after total knee arthroplasty. Over this time, there has been significant research into the optimal choice of pharmacologic VTE prophylaxis for individual patients, with the objective to reduce the rate of VTE while minimizing adverse side effects such as bleeding. Recently, aspirin has emerged as a promising prophylactic agent for patients undergoing arthroplasty due to its similar efficacy and good safety profile compared to other pharmacologic agents. However, there is no evidence to date that clearly demonstrates the superiority of any given prophylactic agent. Therefore, this review discusses (1) the current prevalence and trends in VTE after total hip and knee arthroplasty and (2) provides an update on pharmacologic VTE prophylaxis in regard to aspirin usage.
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Affiliation(s)
- Daniel C. Santana
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH 44195, USA; (D.C.S.); (A.K.E.); (M.N.O.); (A.K.K.); (V.E.K.); (R.M.M.)
| | - Ahmed K. Emara
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH 44195, USA; (D.C.S.); (A.K.E.); (M.N.O.); (A.K.K.); (V.E.K.); (R.M.M.)
| | - Melissa N. Orr
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH 44195, USA; (D.C.S.); (A.K.E.); (M.N.O.); (A.K.K.); (V.E.K.); (R.M.M.)
| | - Alison K. Klika
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH 44195, USA; (D.C.S.); (A.K.E.); (M.N.O.); (A.K.K.); (V.E.K.); (R.M.M.)
| | - Carlos A. Higuera
- Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL 33331, USA;
| | - Viktor E. Krebs
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH 44195, USA; (D.C.S.); (A.K.E.); (M.N.O.); (A.K.K.); (V.E.K.); (R.M.M.)
| | - Robert M. Molloy
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH 44195, USA; (D.C.S.); (A.K.E.); (M.N.O.); (A.K.K.); (V.E.K.); (R.M.M.)
| | - Nicolas S. Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH 44195, USA; (D.C.S.); (A.K.E.); (M.N.O.); (A.K.K.); (V.E.K.); (R.M.M.)
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12
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Ratnasekera A, Pulido O, Durgin S, Nichols S, Lozano A, Sienko D, Hanlon A, Martin ND. Venous thromboembolism after penetrating femoral and popliteal artery injuries: an opportunity for increased prevention. Trauma Surg Acute Care Open 2020; 5:e000468. [PMID: 32566757 PMCID: PMC7295438 DOI: 10.1136/tsaco-2020-000468] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/05/2020] [Accepted: 05/13/2020] [Indexed: 11/12/2022] Open
Abstract
Background Trauma patients with penetrating vascular injuries have a higher rate of venous thromboembolism (VTE). The objective of this study was to determine the risk of VTE formation in penetrating femoral and popliteal vascular injuries and the effects of endovascular management of these injuries. Methods A retrospective study of Pennsylvania Trauma Outcome Study registry was conducted during a 5-year period (2013–2017). All adult patients with a penetrating mechanism with femoral/popliteal vascular injuries were studied. Primary outcome was incidence of VTE in patients with isolated arterial injuries versus combined arterial/venous injuries. Secondary endpoints were intensive care unit (ICU) length of stay (LOS), hospital LOS and mortality. Statistical comparisons were accomplished using Fisher’s exact tests, and parametric two-sample t-tests or non-parametric Wilcoxon rank-sum tests for categorical and continuous variables, respectively. Results Of the 865 patients with penetrating extremity vascular injuries, 207 had femoral or popliteal artery injuries. Patients with isolated arterial injuries (n=131) had a significantly lower deep venous thrombosis (DVT) rate compared with those with concurrent venous injuries (n=76) (3.1% vs. 13.2%, p=0.008). There were 14 patients in the study who developed DVTs. Among the four patients with isolated femoral or popliteal arterial injuries who had developed DVTs, three had an open repair. Among patients with isolated arterial injuries, those with DVT spend significantly more time on the ventilator (median=2 vs. 0, p=0.0020) compared with patients without DVT. Patients with DVT also had longer stay in the hospital (median=17.5 vs. 8, p=0.0664) and in the ICU (median=3 vs. 1, p=0.0585). Conclusions Risk of DVT exists in patients with penetrating isolated femoral and popliteal artery trauma. Open repair was associated with significantly higher DVT rates in isolated arterial injuries. Level of evidence Level IV therapeutic care/management.
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Affiliation(s)
- Asanthi Ratnasekera
- Department of Surgery, Crozer-Keystone Health System, Upland, Pennsylvania, USA
| | - Odessa Pulido
- Department of Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, USA
| | - Sandra Durgin
- Department of Surgery, Crozer-Keystone Health System, Upland, Pennsylvania, USA
| | - Sharon Nichols
- Department of Surgery, Crozer-Keystone Health System, Upland, Pennsylvania, USA
| | - Alicia Lozano
- Department of Statisitics, Virginia Polytechnic Institute and State University, Center for Biostatistics and Health Data Science, Roanoke, Virginia, USA
| | - Danielle Sienko
- Department of Statisitics, Virginia Polytechnic Institute and State University, Center for Biostatistics and Health Data Science, Roanoke, Virginia, USA
| | - Alexandra Hanlon
- Department of Statisitics, Virginia Polytechnic Institute and State University, Center for Biostatistics and Health Data Science, Roanoke, Virginia, USA
| | - Niels D Martin
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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13
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Scala E, Coutaz C, Gomez F, Alberio L, Marcucci C. Comparison of ROTEM Sigma to Standard Laboratory Tests and Development of an Algorithm for the Management of Coagulopathic Bleeding in a Tertiary Center. J Cardiothorac Vasc Anesth 2020; 34:640-649. [DOI: 10.1053/j.jvca.2019.10.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 10/03/2019] [Accepted: 10/07/2019] [Indexed: 01/17/2023]
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A meta-analysis on anticoagulation after vascular trauma. Eur J Trauma Emerg Surg 2020; 46:1291-1299. [PMID: 32067052 PMCID: PMC7691301 DOI: 10.1007/s00068-020-01321-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 02/04/2020] [Indexed: 11/05/2022]
Abstract
Purpose There is much debate regarding the use of anticoagulation following vascular trauma. The aim of this meta-analysis was to compare the outcome of trauma following administration of anticoagulation medication. Methods The literature search was carried out using Ovid MEDLINE and PubMed databases to search for keywords and MeSH terms including “Anticoagulation”, “Vascular Surgery”, “Vascular Trauma”, “Vascular Repair”, “Repair” and “Wounds and Injuries”. Results Use of anticoagulation was associated with a better prognosis for overall vascular trauma outcomes (weighted OR 0.46; 95% CI 0.34–0.64; P < 0.00001), as well as reduced risk of amputation for both lower and upper limb vascular trauma (weighted OR 0.42; 95% CI 0.22–0.78; P = 0.007), and reduced occurrence of reoperation events and amputations in isolated lower limb vascular trauma (weighted OR 0.27; 95% CI 0.14–0.52; P < 0.0001). Conclusion There was a statistically significant correlation between the use of anticoagulation and vascular trauma outcome. A major limitation with many of the studies includes a lack of prospective analysis and therefore we recommend prospective studies to properly elucidate prognostic outcomes following use of these anticoagulants. Further studies need to be conducted to assess the effects of timing of anticoagulant delivery, dosages and severity of traumatic injury. Thus, this would prove to be very useful in the formation of guidelines.
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15
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Underdosing of Prophylactic Enoxaparin Is Common in Orthopaedic Trauma and Predicts 90-Day Venous Thromboembolism. J Orthop Trauma 2019; 33:570-576. [PMID: 31634287 DOI: 10.1097/bot.0000000000001563] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine the feasibility and impact of real-time anti-factor Xa (aFXa) level monitoring and enoxaparin dose adjustment in orthopaedic trauma. To examine the adequacy of standard fixed-dose enoxaparin chemoprophylaxis and to examine whether patient-specific factors influence enoxaparin metabolism. DESIGN Prospective cohort. SETTING Academic Level-I trauma center. PATIENTS Postoperative adult orthopaedic trauma patients undergoing acute fracture or nonunion surgery of the pelvis, acetabulum, or lower extremity placed on 30 mg of enoxaparin twice daily. INTERVENTION Peak steady-state aFXa levels were drawn with a goal range of 0.2-0.4 IU/mL. Patients with out-of-range levels underwent a 10-mg dose adjustment followed by repeat aFXa draws. MAIN OUTCOME MEASURES Peak and trough aFXa levels, 90-day venous thromboembolism, and bleed events. RESULTS Of 109 enrolled patients, 43% had inadequate initial peak aFXa levels (aFXa < 0.2 IU/mL) with standard dosing. Higher gross weight, acetabular surgery, and operation length predicted low aFXa levels (P < 0.001, 0.006, 0.004, respectively). Dose adjustment increased the proportion of patients with in-range aFXa levels from 53.2% to 87.8% (P < 0.001). Patients with low aFXa levels during hospitalization or at discharge had significantly higher 90-day deep vein thrombosis and pulmonary embolism rates compared to those with adequate aFXa levels (deep vein thrombosis 12% vs. 1.36%; P = 0.023, pulmonary embolism 8% vs. 0%; P = 0.027). There were no major bleed events. CONCLUSIONS Patients receiving inadequate enoxaparin chemoprophylaxis were at significantly increased risk of 90-day venous thromboembolism. Standard fixed-dose enoxaparin provided inadequate chemoprophylaxis in 43% of postoperative orthopaedic trauma patients, which significantly improved with dose adjustment. Weight, acetabular surgery, and operation length predicted inadequate enoxaparin prophylaxis. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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16
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Blackwood SL, O'Leary JJ, Scully RE, Lotto CE, Nguyen LL, Gravereaux EC, Menard MT, Ozaki CK, Gates JD, Belkin M. Emergency intraoperative vascular surgery consultations at a tertiary academic center. J Vasc Surg 2019; 71:967-978. [PMID: 31515177 DOI: 10.1016/j.jvs.2019.05.064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 05/29/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Vascular surgeons are frequently called on to provide emergency assistance to surgical colleagues. Whereas previous studies have included elective preoperative vascular consultations, we sought to characterize the breadth of assistance provided during unplanned intraoperative consultations at a single tertiary academic center. METHODS We queried our institutional billing department during a 15-year period and reviewed the records (January 1, 2002-December 31, 2016) and identified unanticipated unplanned vascular surgery intraoperative consultations from all surgical services. Patients' demographics and comorbidities were recorded along with the consulting services, type of index operation, reasons for vascular consultation, regions of anatomic interventions, type of vascular interventions performed, and outcomes achieved. RESULTS There were 419 emergency intraoperative consultations identified. Patients were 51% male, with an average age of 57 years and body mass index of 28.3 kg/m2. The most frequently consulting subspecialties included surgical oncology (n = 139 [33.2%]), cardiac surgery (n = 82 [19.6%]), and orthopedics (n = 44 [10.5%]). Index cases were elective/nonurgent (n = 324 [77.3%]), urgent (n = 27 [6.4%]), and emergent (n = 68 [16.2%]), with a majority involving tumor resection (n = 240 [57.3%]). The primary reasons for vascular consultation were revascularization (n = 213 [50.8%]), control of bleeding (n = 132 [31.5%]), assistance with dissection or exposure (n = 46 [11%]), embolic protection (n = 24 [5.7%]), and other (n = 4 [1.1%]). The primary blood vessel and anatomic field of intervention were categorized. Most cases (n = 264 [63%]) included preservation of blood flow, including primary arterial repair (n = 181 [43.2%]), patch angioplasty (n = 83 [19.8%]), bypass (n = 63 [15%]), and thrombectomy (n = 38 [9.1%]). Postoperative mean length of stay was 15 days, with 30-day and 1-year mortality of 7.2% and 26.5%. CONCLUSIONS Vascular surgeons are called on to provide unplanned open surgical consultations for a wide variety of specialties over wide-ranging anatomic regions, employing a variety of skills and techniques. This study testifies to the essential services supplied to hospitals and our surgical colleagues along with the broad skills and training necessary for modern vascular surgeons.
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Affiliation(s)
- Stuart L Blackwood
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, Mass.
| | - James J O'Leary
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Rebecca E Scully
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Christine E Lotto
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Louis L Nguyen
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Edwin C Gravereaux
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Matthew T Menard
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, Mass
| | - C Keith Ozaki
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, Mass
| | | | - Michael Belkin
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, Mass
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17
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Hossfeld B, Lechner R, Josse F, Bernhard M, Walcher F, Helm M, Kulla M. [Prehospital application of tourniquets for life-threatening extremity hemorrhage : Systematic review of literature]. Unfallchirurg 2019; 121:516-529. [PMID: 29797031 DOI: 10.1007/s00113-018-0510-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION The effectiveness of a tourniquet in the case of life-threatening hemorrhages of the extremities is well recognized and led to the recommendations on "Tourniquet" of the German Society of Anaesthesiology and Intensive Care (DGAI) in 2016. The aim of this systematic review was to re-evaluate the current medical literature in relation to the published DGAI recommendations. MATERIAL AND METHODS Based on the analysis of all studies published from January 2015 until January 2018 in the PubMed databases, the publicized recommendations for action on "Tourniquet" of the DGAI were critically re-evaluated. For this purpose, 17 questions on 6 subjects were formulated in advance. The systematic review followed the PRISMA recommendations and is registered in PROSPERO (International prospective register of systematic reviews, Reg.-ID: CRD42018091528). RESULTS Of the 284 studies identified with the keywords tourniquet and trauma in the period from January 2015 to January 2018 in PubMed, 50 original papers discussing the prehospital application of tourniquet for life-threatening hemorrhage of the extremities were included. The overall level of evidence is low. No article addressed any of the formulated questions with a prospective randomized interventional study. Scientific deductions could be found only in an indirect way in a descriptive manner. CONCLUSION The 50 original articles included in this qualitative, systematic review revealed that the recommendations "Tourniquet" of the DGAI published in 2016 are mostly still up to date despite an inhomogeneous study situation. A deviation occurred in the conversion of a tourniquet but due to the short prehospital treatment time in the civilian setting this is of little importance; however, in the future a strict distinction should be made between tourniquets which were placed for tactical reasons and those placed as a medical necessity.
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Affiliation(s)
- B Hossfeld
- Klinik für Anästhesiologie und Intensivmedizin, Sektion Notfallmedizin, Bundeswehrkrankenhaus Ulm, Oberer Eselsberg 40, 89081, Ulm, Deutschland.,Arbeitsgruppe "Taktische Medizin", Arbeitskreises Notfallmedizin, Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin, Nürnberg, Deutschland.,Tactical Rescue and Emergency Medicine Association (TREMA e. V.), Tübingen, Deutschland
| | - R Lechner
- Klinik für Anästhesiologie und Intensivmedizin, Sektion Notfallmedizin, Bundeswehrkrankenhaus Ulm, Oberer Eselsberg 40, 89081, Ulm, Deutschland.,Tactical Rescue and Emergency Medicine Association (TREMA e. V.), Tübingen, Deutschland
| | - F Josse
- Klinik für Anästhesiologie und Intensivmedizin, Sektion Notfallmedizin, Bundeswehrkrankenhaus Ulm, Oberer Eselsberg 40, 89081, Ulm, Deutschland.,Arbeitsgruppe "Taktische Medizin", Arbeitskreises Notfallmedizin, Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin, Nürnberg, Deutschland.,Tactical Rescue and Emergency Medicine Association (TREMA e. V.), Tübingen, Deutschland
| | - M Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland.,Arbeitsgruppe "Trauma- und Schockraummanagement", Arbeitskreis Notfallmedizin, Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin, Nürnberg, Deutschland
| | - F Walcher
- Universitätsklinik für Unfallchirurgie, Universitätsklinikum Magdeburg, Magdeburg, Deutschland.,Sektion Notfall‑, Intensivmedizin und Schwerverletztenversorgung (NIS), Deutsche Gesellschaft für Unfallchirurgie (DGU), Berlin, Deutschland
| | - M Helm
- Klinik für Anästhesiologie und Intensivmedizin, Sektion Notfallmedizin, Bundeswehrkrankenhaus Ulm, Oberer Eselsberg 40, 89081, Ulm, Deutschland.,Arbeitsgruppe "Taktische Medizin", Arbeitskreises Notfallmedizin, Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin, Nürnberg, Deutschland
| | - M Kulla
- Klinik für Anästhesiologie und Intensivmedizin, Sektion Notfallmedizin, Bundeswehrkrankenhaus Ulm, Oberer Eselsberg 40, 89081, Ulm, Deutschland. .,Arbeitsgruppe "Taktische Medizin", Arbeitskreises Notfallmedizin, Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin, Nürnberg, Deutschland. .,Sektion Notfall‑, Intensivmedizin und Schwerverletztenversorgung (NIS), Deutsche Gesellschaft für Unfallchirurgie (DGU), Berlin, Deutschland.
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18
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Dynamic coagulability after injury: Is delaying venous thromboembolism chemoprophylaxis worth the wait? J Trauma Acute Care Surg 2019; 85:907-914. [PMID: 30124623 DOI: 10.1097/ta.0000000000002048] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Severely injured patients often progress from early hypocoagulable to normal and eventually hypercoagulable states, developing increased risk for venous thromboembolism (VTE). Prophylactic anticoagulation can decrease this risk, but its initiation is frequently delayed for extended periods due to concerns for bleeding. To facilitate timely introduction of VTE chemoprophylaxis, we characterized the transition from hypo- to hypercoagulability and hypothesized that trauma-induced coagulopathy resolves within 24 hours after injury. METHODS Serial blood samples were collected prospectively from critically injured patients for 120 hours after arrival at an urban Level I trauma center. Extrinsic thromboelastometry maximum clot firmness was used to classify patients as hypocoagulable (HYPO, <49 mm), normocoagulable (NORM, 49-71 mm), or hypercoagulable (HYPER, >71 mm) at each time point. Changes in coagulability over hospital course, VTE occurrence, and timing of prophylaxis initiation were analyzed. RESULTS 898 patients (median Injury Severity Score, 13; mortality, 12%; VTE, 8%) were enrolled. Upon arrival, 3% were HYPO (90% NORM, 7% HYPER), which increased to 9% at 6 hours before down-trending. Ninety-seven percent were NORM by 24 hours, and 53% were HYPER at 120 hours. Median maximum clot firmness began in the NORM range, up-trended gradually, and entered the HYPER range at 120 hours. Patients with traumatic brain injury (TBI) followed a similar course and were not more HYPO at any time point than those without TBI. Failure to initiate prophylaxis by 72 hours was predicted by TBI and associated with VTE development (27% vs 16%, p < 0.05). CONCLUSIONS Regardless of injury pattern, trauma-induced coagulopathy largely resolves within 24 hours, after which hypercoagulability becomes increasingly more prevalent. Deferring initiation of chemoprophylaxis, which is often biased toward patients with intracranial injuries, is associated with VTE development. LEVEL OF EVIDENCE Prognostic study, level III; Therapeutic, level IV.
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Dijkink S, Krijnen P, Hage A, Van der Wilden GM, Kasotakis G, Hartog DD, Salim A, Goslings JC, Bloemers FW, Rhemrev SJ, King DR, Velmahos GC, Schipper IB. Differences in Characteristics and Outcome of Patients with Penetrating Injuries in the USA and the Netherlands: A Multi-institutional Comparison. World J Surg 2018; 42:3608-3615. [PMID: 29785695 PMCID: PMC6182736 DOI: 10.1007/s00268-018-4669-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
INTRODUCTION The incidence and nature of penetrating injuries differ between countries. The aim of this study was to analyze characteristics and clinical outcomes of patients with penetrating injuries treated at urban Level-1 trauma centers in the USA (USTC) and the Netherlands (NLTC). METHODS In this retrospective cohort study, 1331 adult patients (470 from five NLTC and 861 from three USTC) with truncal penetrating injuries admitted between July 2011 and December 2014 were included. In-hospital mortality was the primary outcome. Outcome comparisons were adjusted for differences in population characteristics in multivariable analyses. RESULTS In USTC, gunshot wound injuries (36.1 vs. 17.4%, p < 0.001) and assaults were more frequent (91.2 vs. 77.7%, p < 0.001). ISS was higher in USTC, but the Revised Trauma Score (RTS) was comparable. In-hospital mortality was similar (5.0 vs. 3.6% in NLTC, p = 0.25). The adjusted odds ratio for mortality in USTC compared to NLTC was 0.95 (95% confidence interval 0.35-2.54). Hospital stay length of stay was shorter in USTC (difference 0.17 days, 95% CI -0.29 to -0.05, p = 0.005), ICU admission rate was comparable (OR 0.96, 95% CI 0.71-1.31, p = 0.80), and ICU length of stay was longer in USTC (difference of 0.39 days, 95% CI 0.18-0.60, p < 0.0001). More USTC patients were discharged to home (86.9 vs. 80.6%, p < 0.001). Readmission rates were similar (5.6 vs. 3.8%, p = 0.17). CONCLUSION Despite the higher incidence of penetrating trauma, particularly firearm-related injuries, and higher hospital volumes in the USTC compared to the NLTC, the in-hospital mortality was similar. In this study, outcome of care was not significantly influenced by differences in incidence of firearm-related injuries.
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Affiliation(s)
- Suzan Dijkink
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Pieta Krijnen
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Aglaia Hage
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | | | - George Kasotakis
- Division of Trauma, Acute Care Surgery and Surgical Critical Care, Department of Surgery, Boston University School of Medicine, Boston, MA USA
| | - Dennis den Hartog
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ali Salim
- Division of Trauma, Burn and Surgical Critical Care and Emergency General Surgery, Brigham and Women’s Hospital, Boston, MA USA
| | - J. Carel Goslings
- Department of Trauma Surgery, Academic Medical Center, Amsterdam, The Netherlands
- Present Address: Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Frank W. Bloemers
- Department of Trauma Surgery, Vrije Universiteit Medical Center, Amsterdam, The Netherlands
| | - Steven J. Rhemrev
- Department of Trauma Surgery, Haaglanden Medical Center Westeinde, The Hague, The Netherlands
| | - David R. King
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, USA
| | - George C. Velmahos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, USA
| | - Inger B. Schipper
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, The Netherlands
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20
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Xiang Y, Xiong F, Zhao J, Huang B. Regarding "Isolated iliac vascular injuries and outcome of repair versus ligation of isolated iliac vein injury". J Vasc Surg 2018; 67:1940. [PMID: 29801563 DOI: 10.1016/j.jvs.2018.03.397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 03/02/2018] [Indexed: 02/05/2023]
Affiliation(s)
- Yuwei Xiang
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Fei Xiong
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jichun Zhao
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Bin Huang
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, China
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