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Siddiqi N, Lammers D, Hu P, Stonko D, DuBose J, Hurst S, Hashmi Z, Morrison J, Betzold R. Comparison of Contralateral vs Ipsilateral Vein Graft for Traumatic Vascular Injury Repair: A Cohort From PROOVIT. Am Surg 2024:31348241246167. [PMID: 38621410 DOI: 10.1177/00031348241246167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
Traumatic injury leading to arterial damage has traditionally been repaired using autologous vein graft from the contralateral limb. This often requires a secondary surgical site and the potential of prolonged operative time for patients. We sought to assess the use of ipsilateral vs contralateral vein grafts in patients who experienced traumatic extremity vascular injury. A multicenter database was queried to identify arterial injuries requiring operative intervention with vein grafting. The primary outcome of interest was need for operative reintervention. Secondary outcomes included risk of thrombosis, infection, and intensive care unit length of stay. 358 patients (320 contralateral and 38 ipsilateral) were included in the analysis. The ipsilateral vein cohort did not display a statistically significant decrease in need for reoperation when compared to the contralateral group (11% vs 23%; OR 0.41, 95% CI -0.07-1.3; P = .14). Contralateral repair was associated with longer median intensive care unit (ICU) LOS (4.3 vs 3.1 days; P < .01).
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Affiliation(s)
- Noreen Siddiqi
- Department of Surgery, The University of Alabama at Birmingham Hospital, Birmingham, AL, USA
| | - Daniel Lammers
- Department of Surgery, The University of Alabama at Birmingham Hospital, Birmingham, AL, USA
| | - Parker Hu
- Department of Surgery, Chippenham Hospital, Richmond, VA, USA
| | - David Stonko
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Joseph DuBose
- Department of Surgery and Perioperative Care, The University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Stuart Hurst
- Department of Surgery, The University of Alabama at Birmingham Hospital, Birmingham, AL, USA
| | - Zain Hashmi
- Department of Surgery, The University of Alabama at Birmingham Hospital, Birmingham, AL, USA
| | - Jonathan Morrison
- Department of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Richard Betzold
- Department of Surgery, The University of Alabama at Birmingham Hospital, Birmingham, AL, USA
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Stafforini NA, Singh N. Management of Vascular Injuries in Penetrating Trauma. Surg Clin North Am 2023; 103:801-825. [PMID: 37455038 DOI: 10.1016/j.suc.2023.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Management of vascular trauma remains a challenge and traumatic injuries result in significant morbidity and mortality. Vascular trauma can be broadly classified according to mechanism of injury (iatrogenic, blunt, penetrating, and combination injuries). In addition, this can be further classified by anatomical area (neck, thoracic, abdominal, pelvic, and extremities) or contextual circumstances (civilian and military).
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Affiliation(s)
- Nicolas A Stafforini
- Division of Vascular Surgery, Department of Surgery, University of Washington, 325 9th Avenue, Box 359908, Seattle, WA 98104, USA
| | - Niten Singh
- Division of Vascular Surgery, Department of Surgery, University of Washington, 325 9th Avenue, Box 359908, Seattle, WA 98104, USA.
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Shaikh SP, Haqqani MH, Alfson DB, Forsyth A, Brea F, Richman A, Siracuse JJ, Rybin D, Eberhardt RT, Farber A, Brahmbhatt TS. Outcomes following ipsilateral great saphenous vein bypass for lower extremity arterial injuries. Injury 2023:S0020-1383(23)00286-3. [PMID: 36973136 DOI: 10.1016/j.injury.2023.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 02/15/2023] [Accepted: 03/20/2023] [Indexed: 03/29/2023]
Abstract
OBJECTIVE Use of autologous great saphenous vein (GSV) grafts for repair of extremity arterial injuries is well established. Contralateral great saphenous vein (cGSV) is traditionally used in the setting of lower extremity vascular injury given the risk of occult ipsilateral superficial and deep venous injury. We evaluated outcomes of ipsilateral GSV (iGSV) bypass in patients with lower extremity vascular trauma. METHODS Patient records at an ACS verified Level I urban trauma center between 2001 and 2019 were retrospectively reviewed. Patients who sustained lower extremity arterial injuries managed with autologous GSV bypass were included. Propensity-matched analysis compared the iGSV and cGSV groups. Primary graft patency was assessed via Kaplan-Meier analysis at 1-year and 3-years following the index operation. RESULTS A total of 76 patients underwent autologous GSV bypass for lower extremity vascular injuries. 61 cases (80%) were secondary to penetrating trauma, and 15 patients (20%) underwent repair with iGSV bypass. Arteries injured in the iGSV group included popliteal (33.3%), common femoral (6.7%), superficial femoral (33.3%), and tibial (26.7%), while those in the cGSV group included common femoral (3.3%), superficial femoral (54.1%), and popliteal (42.6%). Reasons for using iGSV included trauma to the contralateral leg (26.7%), relative accessibility (33.3%), and other/unknown (40%). On unadjusted analysis, iGSV patients had a higher rate of 1-year amputation than cGSV patients (20% vs. 4.9%), but this was not statistically significant (P = 0.09). Propensity matched analysis also found no significant difference in 1-year major amputation (8.3% vs. 4.8%, P = 0.99). Regarding ambulatory status, iGSV patients had similar rates of independent ambulation (33.3% vs. 38.1%), need for assistive devices (58.3% vs. 57.1%), and use of a wheelchair (8.3% vs. 4.8%) compared cGSV patients at subsequent follow-up (P = 0.90). Kaplan-Meier analysis of bypass grafts revealed comparable primary patency rates for iGSV versus cGSV bypasses at 1-year (84% vs. 91%) and 3-years post-intervention (83% vs. 90%, P = 0.364). CONCLUSION Ipsilateral GSV may be used as a durable conduit for bypass in cases of lower extremity arterial trauma where use of contralateral GSV is not feasible, with comparable long-term primary graft patency rates and ambulatory status.
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Affiliation(s)
- Shamsh P Shaikh
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
| | - Maha H Haqqani
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
| | - Daniel B Alfson
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
| | - Alexandra Forsyth
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
| | - Fernando Brea
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
| | - Aaron Richman
- Division of Trauma, Acute Care Surgery and Surgical Critical Care, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, 840 Harrison Ave, Dowling 2 South, Suite 2509, Boston, MA, 02118, United States
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
| | - Denis Rybin
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
| | - Robert T Eberhardt
- Evans Department of Medicine and Whitaker Cardiovascular Institute, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
| | - Tejal S Brahmbhatt
- Division of Trauma, Acute Care Surgery and Surgical Critical Care, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, 840 Harrison Ave, Dowling 2 South, Suite 2509, Boston, MA, 02118, United States.
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Xie L, Zeng X, Xia Q, Peng J, Liu F, Chen J, Liu J, Xiao X, Liu J, Li H, Wang Z. Reconstruction of a Transplant Recipient's External Iliac Artery Using Donor's Inferior Vena Cava in Renal Transplantation: 2 Case Reports. Transplant Proc 2020; 53:828-832. [PMID: 33004221 DOI: 10.1016/j.transproceed.2020.08.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 08/08/2020] [Indexed: 10/23/2022]
Abstract
Iliac atherosclerosis is common in renal transplant recipients. In severe cases, it affects intraoperative renal arterial anastomosis and increases the risk of postanastomosis complications. At present, safe and efficient vascular replacement methods are relatively limited. In the 2 renal transplant cases at our center, described here, the donors' iliac arteries were unavailable. We therefore attempted to replace the recipients' diseased external iliac artery with the donors' inferior vena cava and then performed an end-to-side grafting with the attachment in arterial reconstruction. One patient received a single kidney transplantation, while the other received a dual kidney transplantation. Antiplatelet/anticoagulation drug application was avoided, and both patients were observed for more than 6 months. Stable renal graft function was achieved without any vascular complications. During this study, all procedures were in compliance with the Helsinki Congress and the Declaration of Istanbul. For end-stage renal disease patients with severe iliac atherosclerosis who are waiting for kidney transplantation, a donor's vena cava graft could potentially be a promising replacement option to restore external iliac artery patency and reconstruct renal blood flow, without the necessity of harvesting a recipient's autologous vessels or looking for costly artificial ones.
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Affiliation(s)
- Liangbo Xie
- Department of Urology, Union Hospital, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, China
| | - Xianpeng Zeng
- Department of Urology, Union Hospital, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, China
| | - Qiuxiang Xia
- Department of Urology, Union Hospital, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, China
| | - Jingtao Peng
- Department of Urology, Union Hospital, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, China
| | - Fangning Liu
- Department of Urology, Union Hospital, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, China
| | - Jing Chen
- Department of Urology, Union Hospital, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, China
| | - Jiali Liu
- Department of Urology, Union Hospital, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, China
| | - Xiong Xiao
- Department of Urology, Union Hospital, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, China
| | - Jing Liu
- Department of Urology, Union Hospital, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, China
| | - Heng Li
- Department of Urology, Union Hospital, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, China
| | - Zhendi Wang
- Department of Urology, Union Hospital, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, China.
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Brumberg RS, Kaelin LD, Derosier LC, Hutchinson H. Early Results of Supporting Free Flap Coverage of Mangled Lower Extremities with Long Saphenous Arteriovenous Loop Grafts. Ann Vasc Surg 2020; 71:181-190. [PMID: 32800890 DOI: 10.1016/j.avsg.2020.07.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 07/20/2020] [Accepted: 07/29/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The ability to salvage the mangled lower extremity is both technically challenging and time consuming. It requires the collaborative efforts among multiple surgical specialties in addition to comprehensive post-traumatic wound follow-up. Our institution has integrated a dynamic effort among these specialists in the planning and facilitating a successful limb salvage program with creation of a mangled extremity algorithm. An integral part in this process is the vascular inflow to prepare coverage for large tissue defects lacking adequate recipient targets. Utilization of long saphenous arteriovenous (AV) loop has been cited with minimal data available using larger inflow vessels in the acute trauma setting. We performed a retrospective review and describe our early experience using our protocol with AV loop creation with free flap reconstruction to salvage traumatic leg injuries. Using the data, we sought to develop a mangled extremity protocol for trauma centers to guide mangled limb salvage. METHODS Since June 2016, 398 patients were admitted to our level II trauma facility with isolated traumatic wounds to the lower extremities. Thirty-one limbs were deemed mangled in which 21 received primary amputations due to multiple factors. Ten patients admitted from the trauma service with isolated mangled lower extremities injuries were identified for review. All 10 patients sustained severe crush injuries with large soft tissue defects and decreased perfusion for healing but deemed salvageable by multispecialty assessment. Mangled extremity severity scores were tabulated. Patients age ranged from 21-44 years, with 8 men and 2 women. Repeated debridements until successful sterilization of the wounds were accomplished. Ten long saphenous vein AV loops were anastomosed to the at or above knee popliteal vessels for free flap reconstruction. All patients were followed post-AV loop creation for vascular complications and wound assessments. RESULTS All 10 patients had sterilization of the wounds with repair of the fracture site before vascular reconstruction. Mean debridement to surgical site sterilization was 4.3 washouts (range 2-7). Successful AV loop creation with long saphenous vein was completed in 100% of patients without vascular complications nor steal events. Free flap tissue transfers directly connected to the loop were completed using 6 rectus abdominis, 3 latissimus dorsi, and 1 anterior thigh graft within 10 days of its creation. Patency rates of the AV loop was 100% with 10 successful flap transfers and 90% amputation free survival. One flap did not survive due to recurrent bacterial infection of the hardware. The 9 patients with successful procedures reached preoperative ambulatory status within 3 months after their final surgery. At 24 months follow-up, 90% amputation free survival is still maintained. CONCLUSIONS Although a small patient cohort, utilization of long saphenous vein AV loop is successful as a bridge to free flap transfer for isolated mangled lower extremities. Development and incorporation of our mangled extremity protocol to guide limb salvage has proven successful in our early experience. Long-term data need to be complied to assess patency of the free flap transfer and quality of life outcomes.
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