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Forsyth A, Haqqani MH, Alfson DB, Shaikh SP, Brea F, Richman A, Siracuse JJ, Rybin D, Farber A, Brahmbhatt TS. Long-term outcomes of autologous vein bypass for repair of upper and lower extremity major arterial trauma. J Vasc Surg 2024; 79:1339-1346. [PMID: 38301809 DOI: 10.1016/j.jvs.2024.01.204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 01/12/2024] [Accepted: 01/25/2024] [Indexed: 02/03/2024]
Abstract
OBJECTIVE Autologous vein is the preferred bypass conduit for extremity arterial injuries owing to superior patency and low infection risk; however, long-term data on outcomes in civilians are limited. Our goal was to assess short- and long-term outcomes of autologous vein bypass for upper and lower extremity arterial trauma. METHODS A retrospective review was performed of patients with major extremity arterial injuries (2001-2019) at a level I trauma center. Demographics, injury and intervention details, and outcomes were recorded. Primary outcomes were primary patency at 1 year and 3 years. Secondary outcomes were limb function at 6 months, major amputation, and mortality. Multivariable analysis determined risk factors for functional impairment. RESULTS There were 107 extremity arterial injuries (31.8% upper and 68.2% lower) treated with autologous vein bypass. Mechanism was penetrating in 77% of cases, of which 79.3% were due to firearms. The most frequently injured vessels were the common and superficial femoral (38%), popliteal (30%), and brachial arteries (29%). For upper extremity trauma, concomitant nerve and orthopedic injuries were found in 15 (44.1%) and 11 (32.4%) cases, respectively. For lower extremities, concomitant nerve injuries were found in 10 (13.7%) cases, and orthopedic injuries in 31 (42.5%). Great saphenous vein was the conduit in 96% of cases. Immediate intraoperative bypass revision occurred in 9.3% of patients, most commonly for graft thrombosis. The in-hospital return to operating room rate was 15.9%, with graft thrombosis (47.1%) and wound infections (23.5%) being the most common reasons. The median follow-up was 3.6 years. Kaplan-Meier analysis showed 92% primary patency at 1 year and 90% at 3 years. At 6 months, 36.1% of patients had functional impairment. Of patients with functional impairment at 6 months, 62.9% had concomitant nerve and 60% concomitant orthopedic injuries. Of those with nerve injury, 91.7% had functional impairment, compared with 17.8% without nerve injury (P < .001). Of patients with orthopedic injuries, 51.2% had functional impairment, vs 25% of those without orthopedic injuries (P = .01). On multivariable analysis, concomitant nerve injury (odds ratio, 127.4; 95% confidence interval, 17-957; P <. 001) and immediate intraoperative revision (odds ratio, 11.03; 95% confidence interval, 1.27-95.55; P = .029) were associated with functional impairment. CONCLUSIONS Autologous vein bypass for major extremity arterial trauma is durable; however, many patients have long-term limb dysfunction associated with concomitant nerve injury and immediate intraoperative bypass revision. These factors may allow clinicians to identify patients at higher risk for functional impairment, to outline patient expectations and direct rehabilitation efforts toward improving functional outcomes.
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Affiliation(s)
- Alexandra Forsyth
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Maha H Haqqani
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA.
| | - Daniel B Alfson
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Shams P Shaikh
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Fernando Brea
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Aaron Richman
- Division of Trauma, Acute Care Surgery and Surgical Critical Care, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Denis Rybin
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Tejal S Brahmbhatt
- Division of Trauma, Acute Care Surgery and Surgical Critical Care, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
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Stonko DP, Betzold RD, Azar FK, Edwards J, Abdou H, Elansary NN, Gerling KA, White J, Feliciano DV, DuBose JJ, Morrison JJ. Postoperative antiplatelet and/or anticoagulation use does not impact complication or reintervention rates after vein repair of arterial injury: A PROOVIT study. Vascular 2023; 31:777-783. [PMID: 35430941 DOI: 10.1177/17085381221082371] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
INTRODUCTION The use of antiplatelet (AP) and anticoagulation (AC) therapy after autogenous vein repair of traumatic arterial injury is controversial. The hypothesis in this study was that there is no difference in early postoperative outcomes regardless of whether AC, AP, both, or neither are used. METHODS The American Association for the Surgery of Trauma (AAST) PROspective Observational Vascular Injury Treatment (PROOVIT) registry was queried from November, 2013, to January, 2019, for arterial injuries repaired with a vein graft. Demographics and injury characteristics were compared. Need for in-hospital reoperation was the primary outcome in this four-arm study, assessed with two ordinal logistic regression models (1. no therapy vs. AC only vs. AC and AP; 2. no therapy vs. AP only vs. AC and AP). RESULTS 373 patients (52 no therapy, 88 AP only, 77 AC only, 156 both) from 19 centers with recorded Injury Severity Scores (ISS) were identified. Patients who received no therapy were younger than those who received AP (27.0 vs. 34.2, p = 0.02), had higher transfusion requirement (p < 0.01 between all groups) and a different distribution of anatomic injury (p < 0.01). After controlling for age, sex, ISS, platelet count, hemoglobin, pH, lactate, INR, transfusion requirement and anatomic location, there was no association with postoperative medical therapy and in-hospital operative reintervention, or any secondary outcome, including thrombosis (p = 0.67, p = 0.22). CONCLUSIONS Neither AC nor AP alone, nor in combination, impact complication rate after arterial repair with autologous vein. These patients can be safely treated with or without antithrombotics, recognizing that this study did not demonstrate a beneficial effect.
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Affiliation(s)
- David P Stonko
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Richard D Betzold
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Faris K Azar
- St Mary's Medical Center, West Palm Beach, Florida Atlantic University, Boca Raton, FL USA
| | - Joseph Edwards
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Hossam Abdou
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Noha N Elansary
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | | | - Joseph White
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - David V Feliciano
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Joseph J DuBose
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Jonathan J Morrison
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
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Novack JC, Whitton EL, Smith RN, Sciarretta JD, Nguyen J. Abdominal Wall Evisceration Coupled With Iliac Vascular Injury After Blunt Trauma. Cureus 2023; 15:e34917. [PMID: 36938169 PMCID: PMC10016732 DOI: 10.7759/cureus.34917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2023] [Indexed: 02/17/2023] Open
Abstract
Abdominal evisceration after blunt trauma is uncommon and rarely survivable when coupled with a concomitant iliac vascular injury. Blunt abdominal injury is rarely a cause of abdominal evisceration but may, on occasion, present in patients affected by a unique or high-energy traumatic injury. In these instances, major vascular injury is exceedingly rare but is associated with a high mortality rate. Damage to important vessels that may present more subtly, such as iliac arterial injury, can still be lethal and are important to evaluate in the trauma workup for blunt evisceration. We report the case of a 20-year-old woman who survived an abdominal wall and vascular injury in a motor vehicle accident. Management of this unusual association is discussed.
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Affiliation(s)
- Joseph C Novack
- Department of Medicine, Emory University School of Medicine, Atlanta, USA
| | - Eric L Whitton
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, USA
| | - Randi N Smith
- Department of Surgery, Emory University School of Medicine, Atlanta, USA
| | - Jason D Sciarretta
- Department of Surgery, Emory University School of Medicine, Atlanta, USA
| | - Jonathan Nguyen
- Department of Surgery, Morehouse School of Medicine, Atlanta, USA
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Smith S, Allen L, Khwaja K, Joos E, Ball CG, Engels PT, Naji F, Lampron J, Widder S, Minor S, Jessula S, Parry NG, Vogt KN. Management of vascular trauma across Canada: A cohort study with implications for practice. Injury 2022; 53:1662-1666. [PMID: 35012752 DOI: 10.1016/j.injury.2021.12.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 11/30/2021] [Accepted: 12/29/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND The aim of this study was to provide a description of vascular trauma and its management at trauma centers across Canada. METHODS This retrospective cohort study evaluated patients from 8 Canadian level 1 trauma centers (2011-2015). Medical records were queried to identify adult patients who survived to hospital with major vascular injury. Major vascular injury was defined as injury to named arterial or venous vessels in the legs, arms torso, and neck. Data collected included patient demographics, injury mechanism, injury details, management and clinical outcomes. RESULTS A total of 1330 patients were included. Patients were 76% male with a mean age of 43 (SD 18.8). Reported injuries were 63% blunt, 36% penetrating, and the remainder mixed. The most common specific mechanisms of injury were motor vehicle collision (36%), stabbing (26%), and falls (16%), with gunshot injuries accounting for <5%. Pre-hospital tourniquets were applied in 27 patients (2%). The mean Injury Severity Score (ISS) was 24 (SD 14.5). We identified injuries to named vessels of the neck (32%), thorax (23%), abdomen and pelvis (27%), upper extremity (14%) and lower extremity (10%). Specific vascular injuries included transection (50%), complete occlusion (11%), partial occlusion (39%), and pseudoaneurysm formation (11%). Injuries were managed non-operatively in 32%, with definitive open surgical management (24%), endovascular management (9%) and with damage control techniques in the operating room (3%). Amputation occurred in 10% of lower extremity and 5% of upper extremity injuries. Responsibility for vascular injury management was undertaken by a wide variety of specialists (n = 17). Overall, in-hospital mortality was 13%, and 2% of patients underwent amputation. CONCLUSION This study describes the nature and management of vascular injuries across Canada. The variability in injury mechanisms, management strategies, specialty responsible for management, and outcomes have important implications for practice change and knowledge translation.
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Affiliation(s)
- Shane Smith
- London Health Sciences Centre, London, Ontario, Canada.
| | - Laura Allen
- London Health Sciences Centre, London, Ontario, Canada.
| | - Kosar Khwaja
- McGill University Health Centre, Montreal, Quebec, Canada.
| | - Emilie Joos
- Vancouver Costal Health, Vancouver, British Columbia, Canada.
| | - Chad G Ball
- Foothills Medical Centre, Calgary, Alberta, Canada
| | - Paul T Engels
- Hamilton Health Sciences Centre, Hamilton, Ontario, Canada.
| | - Faysal Naji
- Hamilton Health Sciences Centre, Hamilton, Ontario, Canada.
| | | | - Sandy Widder
- Alberta Health Services, Edmonton, Alberta, Canada.
| | - Sam Minor
- Nova Scotia Health Authority, Halifax, Nova Scotia, Canada.
| | - Samuel Jessula
- Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Neil G Parry
- London Health Sciences Centre, London, Ontario, Canada.
| | - Kelly N Vogt
- London Health Sciences Centre, London, Ontario, Canada.
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Wang H, Tang J, Wu M, Wang X, Zhang T. Application of machine learning missing data imputation techniques in clinical decision making: taking the discharge assessment of patients with spontaneous supratentorial intracerebral hemorrhage as an example. BMC Med Inform Decis Mak 2022; 22:13. [PMID: 35027065 PMCID: PMC8756624 DOI: 10.1186/s12911-022-01752-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 01/06/2022] [Indexed: 11/13/2022] Open
Abstract
Background There are often many missing values in medical data, which directly affect the accuracy of clinical decision making. Discharge assessment is an important part of clinical decision making. Taking the discharge assessment of patients with spontaneous supratentorial intracerebral hemorrhage as an example, this study adopted the missing data processing evaluation criteria more suitable for clinical decision making, aiming at systematically exploring the performance and applicability of single machine learning algorithms and ensemble learning (EL) under different data missing scenarios, as well as whether they had more advantages than traditional methods, so as to provide basis and reference for the selection of suitable missing data processing method in practical clinical decision making. Methods The whole process consisted of four main steps: (1) Based on the original complete data set, missing data was generated by simulation under different missing scenarios (missing mechanisms, missing proportions and ratios of missing proportions of each group). (2) Machine learning and traditional methods (eight methods in total) were applied to impute missing values. (3) The performances of imputation techniques were evaluated and compared by estimating the sensitivity, AUC and Kappa values of prediction models. (4) Statistical tests were used to evaluate whether the observed performance differences were statistically significant. Results The performances of missing data processing methods were different to a certain extent in different missing scenarios. On the whole, machine learning had better imputation performance than traditional methods, especially in scenarios with high missing proportions. Compared with single machine learning algorithms, the performance of EL was more prominent, followed by neural networks. Meanwhile, EL was most suitable for missing imputation under MAR (the ratio of missing proportion 2:1) mechanism, and its average sensitivity, AUC and Kappa values reached 0.908, 0.924 and 0.596 respectively. Conclusions In clinical decision making, the characteristics of missing data should be actively explored before formulating missing data processing strategies. The outstanding imputation performance of machine learning methods, especially EL, shed light on the development of missing data processing technology, and provided methodological support for clinical decision making in presence of incomplete data.
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Edwards J, Abdou H, Patel N, Lang E, Richmond MJ, Rasmussen TE, Scalea TM, Morrison JJ. Open chest selective aortic arch perfusion vs open cardiac massage as a means of perfusion during in exsanguination cardiac arrest: a comparison of coronary hemodynamics in swine. Eur J Trauma Emerg Surg 2022; 48:2089-2096. [PMID: 34984495 DOI: 10.1007/s00068-021-01810-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 10/25/2021] [Indexed: 11/29/2022]
Abstract
AIM To describe and compare the aortic-right atrial pressure (AoP-RAP) gradients and mean coronary perfusion pressures (CPPs) generated during open chest selective aortic arch perfusion (OCSAAP) with those generated during open cardiac massage (OCM) in hypovolemic swine. METHODS Ten male Hanford swine utilized in a prior poly-trauma study were included in the study. Animals were rendered hypovolemic via a 30% volume bleed. Upon confirmation of death, animals underwent immediate clamshell thoracotomy and aortic cross-clamping followed by 5 min of OCM. A catheter suitable for OCSAAP was then inserted into the aorta and animals underwent 1 min of OCSAAP at a rate of 10 mL/kg/min. Aortic and right atrial pressures were recorded continuously using solid-state blood pressure catheters. Representative 10-s intervals from each resuscitation method were extracted. Hemodynamic parameters including AoP-RAP gradients and CPPs were calculated and compared. RESULTS At baseline, time from death to intervention was significantly shorter for OCM. However, mean CPPs and AoP-RAP gradients were significantly higher in animals undergoing OCSAAP. 98% of OCSAAP segments had a mean CPP > 15, compared to 35% of OCM intervals. While OCM had a significant negative correlation between time to intervention and maximum CPP, this correlation was not significant for OCSAAP. CONCLUSION OCSAAP generates favorable and potentially time-resistant pressure gradients when compared to those generated by OCM. Further investigation of the technique of OCSAAP is warranted, as it may have potential utility as a therapy during resuscitative thoracotomy (RT).
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Affiliation(s)
- Joseph Edwards
- Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 S. Greene Street, Baltimore, MD, 21201, USA
| | - Hossam Abdou
- Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 S. Greene Street, Baltimore, MD, 21201, USA
| | - Neerav Patel
- Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 S. Greene Street, Baltimore, MD, 21201, USA
| | - Eric Lang
- Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 S. Greene Street, Baltimore, MD, 21201, USA
| | - Michael J Richmond
- Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 S. Greene Street, Baltimore, MD, 21201, USA
| | - Todd E Rasmussen
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Thomas M Scalea
- Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 S. Greene Street, Baltimore, MD, 21201, USA
| | - Jonathan J Morrison
- Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 S. Greene Street, Baltimore, MD, 21201, USA.
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