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Alkurashi A, Recarey M, Sharma K, Kartiko S, Lala S. Gunshot wound causing penetrating injury to the inferior vena cava treated with open cell self-expanding stents. J Vasc Surg Cases Innov Tech 2024; 10:101565. [PMID: 39188691 PMCID: PMC11345355 DOI: 10.1016/j.jvscit.2024.101565] [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: 05/08/2024] [Accepted: 06/24/2024] [Indexed: 08/28/2024] Open
Abstract
Endovascular stents are predominantly utilized for intra-arterial interventions; however, their application in managing venous injuries, especially traumatic ones, lacks comprehensive guidelines and long-term outcome studies. This case report discusses the innovative deployment of an infrarenal inferior vena cava stent for a traumatic inferior vena cava injury after a gunshot wound in a polytrauma patient. This case aims to enhance the existing evidence on the feasibility and potential outcomes of endovascular stenting in traumatic venous injuries.
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Affiliation(s)
- Adham Alkurashi
- Department of Surgery, George Washington University Hospital, Washington, DC
| | - Melina Recarey
- Department of Surgery, George Washington University Hospital, Washington, DC
| | - Karun Sharma
- Department of Radiology, George Washington University Hospital, Washington, DC
| | - Susan Kartiko
- Department of Surgery, George Washington University Hospital, Washington, DC
| | - Salim Lala
- Department of Surgery, George Washington University Hospital, Washington, DC
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2
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Wikström MB, Stene-Hurtsén A, Åström J, Hörer TM, Nilsson KF. The effect of an endovascular Heaney maneuver to achieve total hepatic isolation on survival, hemodynamic stability, retrohepatic bleeding, and collateral flow in a porcine model. Eur J Trauma Emerg Surg 2024; 50:1547-1557. [PMID: 38456908 PMCID: PMC11458705 DOI: 10.1007/s00068-024-02482-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 02/19/2024] [Indexed: 03/09/2024]
Abstract
PURPOSE Combining resuscitative endovascular balloon occlusion of the aorta (REBOA) and the inferior vena cava (REBOVC) with open surgery is a new hybrid approach for treating retrohepatic vena caval injuries. We compared endovascular total hepatic isolation with supraceliac REBOA ± suprahepatic REBOVC and no occlusion in experimental retrohepatic vena cava bleeding regarding survival, bleeding volume, hemodynamic stability, and arterial collateral blood flow. METHODS Twenty-five anesthetized pigs (n = 6-7/group) were randomized to REBOA; REBOA + REBOVC; REBOA + infra and suprahepatic REBOVC + portal vein occlusion (endovascular Heaney maneuver, four-balloon-occlusion, 4BO) or no occlusion. After balloon inflation, free bleeding was initiated from an open sheath in the retrohepatic vena cava. Bleeding volume, right internal thoracic artery (RITA) blood flow, hemodynamics, and arterial blood variables were measured until death or up to 90 min. RESULTS The REBOA group had a longer median survival time (63 min) compared with the 4BO (24 min, P = 0.02) and no occlusion (30 min, P = 0.02) groups, not versus the REBOA + REBOVC group (49 min, P > 0.05). The first 15 min accumulated bleeding was comparable in all groups (P > 0.05); Thereafter, bleeding volume was higher in the REBOA group versus the 4BO group (P < 0.05), not versus the other groups. RITA blood flow and MAP were higher in the REBOA group versus the other groups after 10 min of bleeding (P < 0.05). CONCLUSIONS Endovascular Heaney maneuver was not beneficial for survival or hemodynamic stability in this porcine model, whereas supraceliac REBOA was. Anatomical differences in thoracoabdominal collaterals between pigs and humans must be considered when interpreting these results.
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Affiliation(s)
- Maria B Wikström
- Department of Emergency, Arvika Hospital, Region Värmland, Arvika, Sweden.
- School of Medical Sciences, Örebro University, Örebro, Sweden.
| | - Anna Stene-Hurtsén
- School of Medical Sciences, Örebro University, Örebro, Sweden
- Department of Cardiothoracic and Vascular Surgery, Department of Surgery, Örebro University Hospital and Faculty of Medicine and Health, Örebro University, Örebro, Region Örebro Län, Sweden
| | - Jens Åström
- Department of Anesthesiology and Intensive Care, Falun Hospital, Falun, Region Dalarna, Sweden
| | - Tal M Hörer
- Department of Cardiothoracic and Vascular Surgery, Department of Surgery, Örebro University Hospital and Faculty of Medicine and Health, Örebro University, Örebro, Region Örebro Län, Sweden
| | - Kristofer F Nilsson
- School of Medical Sciences, Örebro University, Örebro, Sweden
- Department of Cardiothoracic and Vascular Surgery, Department of Surgery, Örebro University Hospital and Faculty of Medicine and Health, Örebro University, Örebro, Region Örebro Län, Sweden
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Haran C, Sivakumaran Y. Contemporary uses of inferior vena cava balloon occlusion. Ann Vasc Surg 2023:S0890-5096(23)00238-8. [PMID: 37121341 DOI: 10.1016/j.avsg.2023.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 04/12/2023] [Accepted: 04/14/2023] [Indexed: 05/02/2023]
Abstract
The evolution of the hybrid operative environment has expanded the utility of inferior vena cava balloon occlusion (IVCBO) in contemporary surgical practice. First described in the management of acute decompensated heart failure and venous thromboembolism, IVCBO has been utilised in deployment of thoracic endoprosthesis, repair of aorto-caval fistula, management of inferior vena cava (IVC) tumour thrombus and abdominal IVC trauma. More recently, IVCBO has also been utilised as a therapeutic strategy to assist patients with reduced ejection fraction and exercise tolerance in the form of an implantable device. Here we present a narrative review of the physiological impact of IVCBO as well as its historical, contemporary and future uses. The contemporary utilisation of IVCBO is a novel example of employing endovascular technology in the hybrid operative environment; paramount for the modern vascular surgeon who is now increasingly involved in multi-disciplinary management of complex clinical presentations.
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Affiliation(s)
- Cheyaanthan Haran
- Department of Vascular Surgery, Auckland City Hospital, Auckland, New Zealand; Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
| | - Yogeesan Sivakumaran
- Department of Vascular Surgery, Princess Alexandra Hospital, Brisbane, Australia; Greater Brisbane Clinical School, University of Queensland, Brisbane, Australia
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Chipman AM, Ottochian M, Ricaurte D, Gunter G, DuBose JJ, Stonko DP, Feliciano DV, Scalea TM, Morrison J. Contemporary management and time to revascularization in upper extremity arterial injury. Vascular 2023; 31:284-291. [PMID: 35418267 DOI: 10.1177/17085381211062726] [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: 11/15/2022]
Abstract
INTRODUCTION Upper extremity arterial injury is associated with significant morbidity and mortality for trauma patients, but there is a paucity of data to guide the clinician in the management of these injuries. The goals of this review were to characterize the demographics, presentation, clinical management, and outcomes, and to evaluate how time to intervention associates with outcomes in trauma patients with upper extremity vascular injuries. METHODS The National Trauma Data Bank (NTDB) Research Data Set for the years 2007-2016 was queried in order to identify adult patients (age ≥ 18) with an upper extremity arterial injury. Patients with brachiocephalic, subclavian, axillary, or brachial artery injury using the 1998 and 2005 versions of the Abbreviated Injury Scale were included. Patients with non-survivable injuries to the brain, traumatic amputation, or other major arterial injuries to the torso or lower extremities were excluded. RESULTS The data from 7908 patients with upper extremity arterial injuries was reviewed. Of those, 5407 (68.4%) underwent repair of the injured artery. The median Injury Severity Score (ISS) was 10 (IQR = 7-18), and 7.7% of patients had a severe ISS (≥ 25). Median time to repair was 120 min (IQR = 60-240 min). Management was open repair in 52.3%, endovascular repair in 7.3%, and combined open and endovascular repairs in 8.8%; amputation occurred in 1.8% and non-operative management was used in 31.6% of patients. Blunt mechanism of injury, crush injury, concomitant fractures/dislocations, and nerve injuries were associated with amputation, whereas simultaneous venous injury was not. There was a significant decrease in the rate of amputation when patients undergoing surgical revascularization did so within 90 min of injury (P = 0.007). CONCLUSION Injuries to arteries of the upper extremity are managed with open repair, endovascular repair, and, rarely, amputation. Expeditious transport to the operating room for revascularization is the key for limb salvage.
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Affiliation(s)
- Amanda M Chipman
- 12264University of Maryland School of Medicine, Baltimore, MD, United States
| | - Marcus Ottochian
- 137889R. Adams Cowley Shock Trauma Center, 12264University of Maryland Medical System, Baltimore, Maryland, USA
| | - Daniel Ricaurte
- 12264University of Maryland School of Medicine, Baltimore, MD, United States
| | - Grahya Gunter
- 12264University of Maryland School of Medicine, Baltimore, MD, United States
| | - Joseph J DuBose
- 137889R. Adams Cowley Shock Trauma Center, 12264University of Maryland Medical System, Baltimore, Maryland, USA
| | - David P Stonko
- Department of Surgery, 160877Johns Hopkins Hospital, Baltimore, MD, United States
| | - David V Feliciano
- 12264University of Maryland School of Medicine, Baltimore, MD, United States
| | - Thomas M Scalea
- 137889R. Adams Cowley Shock Trauma Center, 12264University of Maryland Medical System, Baltimore, Maryland, USA
| | - Jonathan Morrison
- 137889R. Adams Cowley Shock Trauma Center, 12264University of Maryland Medical System, Baltimore, Maryland, 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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Heinz ER, Vincent A. Point-of-Care Ultrasound for the Trauma Anesthesiologist. CURRENT ANESTHESIOLOGY REPORTS 2022; 12:217-225. [PMID: 35075351 PMCID: PMC8771171 DOI: 10.1007/s40140-021-00513-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2021] [Indexed: 01/03/2023]
Abstract
Purpose of Review With advances in technology and availability of handheld ultrasound probes, studies are focusing on the perioperative care of patients, but a limited number specifically on trauma patients. This review highlights recent findings from studies using point of care ultrasound (POCUS) to improve the care of trauma patients. Recent Findings Major findings include the use of POCUS to assess volume status of trauma patients upon arrival to measure the major vasculature. Additionally, several studies have advanced the use of POCUS to identify pneumothorax in trauma patients. Finally, the ASA POCUS certification and ASRA expert guidelines are examples of international organizations establishing guidelines for utilization and training of anesthesiologists in the field of POCUS, which will be discussed. Summary Despite the COVID-19 pandemic, and considerable resources being diverted to fight this global healthcare crisis, advances are being made in utilization of POCUS to aid the care of trauma patients.
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Affiliation(s)
- Eric R. Heinz
- Department of Anesthesiology and Critical Care Medicine, George Washington University Medical Faculty Associates, 2300 M Street NW, 7thFloor, Washington, DC 20037 USA
| | - Anita Vincent
- Department of Anesthesiology and Critical Care Medicine, George Washington University Medical Faculty Associates, 2300 M Street NW, 7thFloor, Washington, DC 20037 USA
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Gaibov AD, Sultanov DD, Kalmykov EL, Nematzoda O, Avgonov UM, Baratov AK. [Reconstruction of caval veins]. Khirurgiia (Mosk) 2022:35-43. [PMID: 36223148 DOI: 10.17116/hirurgia202210135] [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: 06/16/2023]
Abstract
OBJECTIVE To study the possibilities and results of reconstruction of caval veins. MATERIAL AND METHODS We analyzed the results of reconstruction of caval veins in 31 patients (19 men and 12 women) including superior vena cava (SVC) in 5 cases and inferior vena cava (IVC) in 26 cases. Penetrating wounds with vascular damage were found in 8 patients. Iatrogenic damage to IVC was observed in 19 patients (nephrectomy for kidney cancer - 2, nephrectomy for secondary kidney wrinkling - 1, echinococcectomy from retroperitoneal space - 1, adrenalectomy for adrenal tumors - 5, right-sided lumbar sympathectomy - 1, resection of abdominal aortic aneurysm - 1, resection of a large retroperitoneal tumor - 6). Iatrogenic damage to SVC occurred in 2 patients during resection of mediastinal tumor. In other 4 cases, elective surgery for mediastinal tumor (1), pancreatic head cancer (2) and liver alveococcosis (1) was accompanied by resection and replacement of caval veins. RESULTS All interventions for caval vein injury were performed under adequate infusion therapy. Seven (22.6%) patients died. One patient with blunt chest trauma and damage to SVC died during thoracotomy. In another patient, infrarenal IVC was intersected during mobilization of retroperitoneal hydatid cyst that required ligation for vital indications. High venous hypertension below the ligature led to eruption of sutures on the venous stump. The patient died from hypovolemia after additional IVC ligation. Other 5 patients died in early postoperative period without leaving the state of shock. These patients had damage to retrohepatic segment of IVC (1), vascular-organ (1) and iatrogenic (3) injuries. One patient died from pulmonary embolism, two patients - from venous bleeding between the 2nd and the 5th postoperative days. Patients died before reoperations. Two patients with postoperative bleeding underwent redo surgery with favorable outcomes. One patient underwent redo surgery for peritonitis with a favorable result. Thus, 7 (22.6%) patients with caval vein injury died in intraoperative and early postoperative period. Non-specific complications occurred in 4 (12.9%) patients. These events were corrected by conservative measures. Other 24 (77.4%) patients with traumatic and iatrogenic injuries of caval veins were discharged. CONCLUSION Caval vein injury is less common event compared to other vascular damages. Nevertheless, this complication is accompanied by severe blood loss, shock and hypovolemia. We can only assume damage to a great vessel in patients with penetrating wounds before surgery and appropriate symptoms of internal bleeding. However, final diagnosis is made during surgery. Hemostasis is a responsible and difficult surgical stage in these patients. There is usually no alternative to reconstructive surgery in these cases. However, ligation is permissible in extremely ill patients and only in infrarenal segment of IVC. Vascular suture is a more acceptable and effective option for reconstruction. However, patch repair is advisable for large defects. In our opinion, this approach is better regarding long-term patency compared to total replacement with synthetic prostheses.
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Affiliation(s)
- A D Gaibov
- Republican Scientific Center for Cardiovascular Surgery, Dushanbe, Tajikistan
- Abuali ibn Sino Tajik State Medical University, Dushanbe, Tajikistan
| | - D D Sultanov
- Republican Scientific Center for Cardiovascular Surgery, Dushanbe, Tajikistan
- Abuali ibn Sino Tajik State Medical University, Dushanbe, Tajikistan
| | | | - O Nematzoda
- Republican Scientific Center for Cardiovascular Surgery, Dushanbe, Tajikistan
| | - U M Avgonov
- Republican Scientific Center for Cardiovascular Surgery, Dushanbe, Tajikistan
| | - A K Baratov
- Republican Scientific Center for Cardiovascular Surgery, Dushanbe, Tajikistan
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