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Noorbakhsh S, Gomez L, Joung Y, Meyer C, Hanos DS, Freedberg M, Klingensmith N, Grant AA, Koganti D, Nguyen J, Smith RN, Sciarretta JD. Hepatic Arterioportal Fistula Following Liver Trauma: Case Series and Review of the Literature. Vasc Endovascular Surg 2023; 57:749-755. [PMID: 36940466 PMCID: PMC10724846 DOI: 10.1177/15385744231165155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2023]
Abstract
PURPOSE Hepatic arterioportal fistula (HAPF) is an uncommon complication of hepatic trauma, which can manifest with abdominal pain and the sequelae of portal hypertension months to years after injury. The purpose of this study is to present cases of HAPF from our busy urban trauma center and make recommendations for management. METHODS One hundred and twenty-seven patients with high-grade penetrating liver injuries (American Association for the Surgery of Trauma [AAST] - Grades IV-V) between January 2019 and October 2022 were retrospectively reviewed. Five patients were identified with an acute hepatic arterioportal fistula following abdominal trauma from our ACS-verified adult Level 1 trauma center. Institutional experience with overall surgical management is described and reviewed with the current literature. RESULTS Four of our patients presented in hemorrhagic shock requiring emergent operative intervention. The first patient had postoperative angiography and coil embolization of the HAPF. Patients 2 through 4 underwent damage control laparotomy with temporary abdominal closure followed by postoperative transarterial embolization with gelatin sponge particles (Gelfoam) or combined Gelfoam/n-butyl cyanoacrylate. The final patient went directly for angiography and Gelfoam embolization after identification of the HAPF. All 5 patients had resolution of HAPF on follow-up imaging with continued post management for traumatic injuries. CONCLUSION Hepatic arterioportal fistula can present as a complication of hepatic injury and manifest with significant hemodynamic aberrations. Although surgical intervention was required to achieve hemorrhage control in almost all cases, management of HAPF in the setting of high-grade liver injuries was achieved successfully with modern endovascular techniques. A multidisciplinary approach to such injuries is necessary to optimize care in the acute setting following traumatic injury.
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Affiliation(s)
- Soroosh Noorbakhsh
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Lissette Gomez
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Yoo Joung
- Grady Memorial Hospital, Atlanta, GA, USA
- Morehouse School of Medicine, Atlanta, GA, USA
| | - Courtney Meyer
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Dustin S. Hanos
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Mari Freedberg
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Nathan Klingensmith
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - April A. Grant
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Deepika Koganti
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Jonathan Nguyen
- Grady Memorial Hospital, Atlanta, GA, USA
- Morehouse School of Medicine, Atlanta, GA, USA
| | - Randi N. Smith
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
- Morehouse School of Medicine, Atlanta, GA, USA
| | - Jason D. Sciarretta
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
- Morehouse School of Medicine, Atlanta, GA, USA
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Keating JJ, Klingensmith N, Moren AM, Skarupa DJ, Loria A, Maher Z, Moore SA, Smith MC, Seamon MJ. Dispelling Dogma: American Association for Surgery of Trauma Prospective, Multicenter Trial of Index vs Delayed Fasciotomy after Extremity Trauma. J Am Coll Surg 2023; 236:1037-1044. [PMID: 36735489 DOI: 10.1097/xcs.0000000000000612] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Surgical dogma states that "if you think about doing a fasciotomy, you do it," yet the benefit of this approach remains unclear. We hypothesized that early fasciotomy during index operative procedures for extremity vascular trauma would be associated with improved patient outcomes. STUDY DESIGN This prospective, observational multicenter (17 level 1, 1 level 2) analysis included patients ≥15 years old with extremity vascular injury requiring operative management. Clinical variables were analyzed with respect to fasciotomy timing for correlation with outcomes, including muscle necrosis and limb amputation. Associated variables (p < 0.05) were input into multivariable logistic regression models evaluating these endpoints. RESULTS Of 436 study patients, most were male (87%) with penetrating (57%), lower extremity (77%), arterial (73%), vein (40%), and bony (53%) injury with prolonged hospital length of stay (11 days). Patients who had index fasciotomy (66%) were compared with those who did not (34%), and no differences were appreciated with respect to age, initial systolic blood pressure, tourniquet time, "hard" signs of vascular injury, massive transfusion protocol activation, or Injury Severity Score (all p < 0.05). Of the 289 patients who underwent index fasciotomy, 49% had prophylactic fasciotomy, 11% developed muscle necrosis, 4% required an additional fasciotomy, and 8% required amputation, although only 28 of 147 (19%) required delayed fasciotomy in those without index fasciotomy. Importantly, forgoing index fasciotomy did not correlate (p > 0.05) with additional muscle necrosis or amputation risk in the delayed fasciotomy group. After controlling for confounders, index surgery fasciotomy was not associated with either muscle necrosis or limb salvage in multivariable models. CONCLUSIONS Routine, index operation fasciotomy failed to demonstrate an outcome benefit in this prospective, multicenter analysis. Our data suggest that a careful observation and fasciotomy-when-needed approach may limit unnecessary surgery and its resulting morbidity in extremity vascular trauma patients.
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Affiliation(s)
- Jane J Keating
- From the Department of Surgery, University of Connecticut School of Medicine, Hartford Hospital, Hartford, CT (Keating)
| | - Nathan Klingensmith
- Department of Surgery, Emory University School of Medicine-Grady Memorial Hospital, Atlanta, GA (Klingensmith)
| | - Alexis M Moren
- Department of Surgery, Oregon Health and Science University-Salem Health, Salem, OR (Moren)
| | - David J Skarupa
- Department of Surgery, University of Florida Health-Jacksonville, Jacksonville, FL Skarupa)
| | - Anthony Loria
- Department of Surgery, University of Rochester School of Medicine, Rochester, NY (Loria)
| | - Zoe Maher
- Department of Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA (Maher)
| | - Sarah A Moore
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM (Moore)
| | - Michael C Smith
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN (Smith)
| | - Mark J Seamon
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA (Seamon)
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Castater C, Noorbakhsh S, Harousseau W, Klingensmith N, Koganti D, Nguyen J, Smith RN, Benarroch-Gampel J, Ramos CR, Rajani R, Sciarretta JD. Missing Bullets: Bullet Embolization Case Series and Review of the Literature. Vasc Endovascular Surg 2023; 57:281-284. [PMID: 36408888 PMCID: PMC10696720 DOI: 10.1177/15385744221141295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE Bullet embolization is a rare but dangerous phenomenon. Based on the location of embolization, migration of bullets can cause limb or intra-abdominal ischemia, pulmonary infarction, cardiac valve injury, or cerebrovascular accident. Bullet emboli can present a diagnostic challenge given the varied nature of complications based on location of embolization, which may not coincide with the site of initial injury. The purpose of this study is to present several cases of bullet embolization from our busy urban trauma center and make recommendations for management. METHODS We present 3 cases of bullet embolization seen in injured patients at our Level 1 trauma center. We describe our management of these injuries and make recommendations for management in the context of our institutional experience and comment on the available literature regarding bullet embolization. RESULTS Two of our patients presented in extremis and required operative intervention to achieve stability. The intravascular missile was discovered intraoperatively in one patient and removed in the operating room, while the missile was discovered on postoperative imaging in another patient and again removed operatively after an unsuccessful attempt at minimally invasive retrieval. Our third patient remained hemodynamically stable throughout his hospitalization and had endovascular management of his bullet embolus. CONCLUSION Bullet emboli present a challenging complication of penetrating trauma. We recommend removal of all arterial bullet emboli and those within the pulmonary venous system. In hemodynamically stable patients, we recommend initial attempts of endovascular retrieval followed by open surgical removal. We recommend open removal in cases of hemodynamic instability.
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Affiliation(s)
| | - Soroosh Noorbakhsh
- Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - William Harousseau
- Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - Nathan Klingensmith
- Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - Deepika Koganti
- Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - Jonathan Nguyen
- Morehouse School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - Randi N. Smith
- Morehouse School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
- Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | | | | | - Ravi Rajani
- Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - Jason D. Sciarretta
- Morehouse School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
- Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
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