Endothelial transferrin receptor 1 contributes to thrombogenesis through cascade ferroptosis

Oxidative stress and iron accumulation-induced ferroptosis occurs in injured vascular cells and can promote thrombogenesis. Transferrin receptor 1 (encoded by the TFRC gene) is an initial element involved in iron transport and ferroptosis and is highly expressed in injured vascular tissues, but its role in thrombosis has not been determined. To explore the potential mechanism and therapeutic effect of TFRC on thrombogenesis, a DVT model of femoral veins (FVs) was established in rats, and weighted correlation network analysis (WGCNA) was used to identify TFRC as a hub protein that is associated with thrombus formation. TFRC was knocked down by adeno-associated virus (AAV) or lentivirus transduction in FVs or human umbilical vein endothelial cells (HUVECs), respectively. Thrombus characteristics and ferroptosis biomarkers were evaluated. Colocalization analysis, molecular docking and coimmunoprecipitation (co-IP) were used to evaluate protein interactions. Tissue-specific TFRC knockdown alleviated iron overload and redox stress, thereby preventing ferroptosis in injured FVs. Loss of TFRC in injured veins could alleviate thrombogenesis, reduce thrombus size and attenuate hypercoagulability. The protein level of thrombospondin-1 (THBS1) was increased in DVT tissues, and silencing TFRC decreased the protein level of THBS1. In vitro experiments further showed that TFRC and THBS1 were sensitive to erastin-induced ferroptosis and that TFRC knockdown reversed this effect. TFRC can interact with THBS1 in the domain spanning from TSR1-2 to TSR1-3 of THBS1. Amino acid sites, including GLN320 of TFRC and ASP502 of THBS1, could be potential pharmacological targets. Erastin induced ferroptosis affected extracellular THBS1 levels and weakened the interaction between TFRC and THBS1 both in vivo and in vitro, and promoted the interaction between THBS1 and CD47. This study revealed a linked relationship between venous ferroptosis and coagulation cascades. Controlling TFRC and ferroptosis in endothelial cells can be an efficient approach for preventing and treating thrombogenesis.

Protective effect of cilostazol on vascular injury in rats with acute ischemic stroke complicated with chronic renal failure

Chronic renal failure (CRF) resulting in vascular calcification, which does damage to blood vessels and endothelium, is an independent risk factor for stroke. It has been reported that cilostazol has a protective effect on the focal cerebral ischemic infarct. However, its impact on vascular injury in CRF combined stroke and its molecular protection mechanism have not been investigated. In this study, we carried out the effect of cilostazol on CRF combined stroke rats, and the results confirmed that it improved the neurobehavior, renal function as well as pathologic changes in both the kidney and brain. In addition, the inflammation and oxidative stress factors in the kidney and brain were suppressed. Moreover, the rates of brain edema and infarction were decreased. The injured brain-blood barrier (BBB) was recovered with less Evans blue extravasation and more expressions of zonula occludens-1(ZO-1) and occludin. More cerebral blood flow (CBF) in the ipsilateral hemisphere and more expression of CD31 and vascular endothelial growth factor (VEGF) in brain and kidney were found in the cilostazol group. Furthermore, cell apoptosis and cell autophagy became less, on the contrary, proteins of vascular endothelial growth factor receptor 2 (VEGFR2) after the cilostazol treatment were increased. More importantly, this protective effect is related to the pathway of Janus Kinase (JAK)/signal transducer and activator of transcription 3 (STAT3), mammalian target of rapamycin (mTOR), and the hypoxia inducible factor-1α (HIF-1α). In conclusion, our results confirmed that cilostazol exerted a protective effect on the brain and kidney function, specifically in vascular injury, oxidative stress, cell apoptosis, cell autophagy, and inflammation response in CRF combined with stroke rats which were related to the upregulation of JAK/STAT3/mTOR signal pathway.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43188-023-00217-w.

The mechanism of selenium regulating the permeability of vascular endothelial cells through selenoprotein O

Vascular diseases, a leading cause of death in human, are strongly associated with pathological damage to blood vessels. The selenoprotein (Sel) have been reported to play important roles in vascular disease. However, the role of SelO in vascular disease has not been conclusively investigated. The present experiment was to investigate the regulatory mechanism of the effect of SelO on the permeability of vascular endothelial. The H.E staining, FITC-Dextran staining, Dil-AC-LDL staining and FITC-WGA staining showed that vascular structure was damaged, and intercellular junctions were disrupted with selenium (Se)-deficient. Immunohistochemistry, qPCR and Western blot revealed decreased expression of the adhesion plaque proteins vinculin, talin and paxillin, decreased expression of the vascular connectivity effector molecules connexin, claudin-1 and E-cadherin and increased expression of JAM-A and N-cadherin, as well as decreased expression of the ZO-1 signaling pathways ZO-1, Rock, rhoGEF, cingulin and MLC-2. In a screening of 24 Sel present in mice, SelO showed the most pronounced changes in vascular tissues, and a possible association between SelO and vascular intercellular junction effectors was determined using IBM SPSS Statistics 25. Silencing of SelO, vascular endothelial intercellular junction adverse effects present. The regulatory relationship between SelO and vascular endothelial intercellular junctions was determined. The results showed that Se deficiency lead to increased vascular endothelial permeability and vascular tissue damage by decreasing SelO expression, suggesting a possible role for SelO in regulating vascular endothelial permeability.

Vascular complications secondary to resuscitative endovascular balloon occlusion of the aorta placement at a Level 1 Trauma Center

INTRODUCTION

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is designed to manage severe hemorrhagic shock. Popularized in medical care during military conflicts, the concept has emerged as a lifesaving technique that is utilized around the United States. Literature on risks of REBOA placement, especially vascular injuries, are not well-reported. Our goal was to assess the incidence of vascular injury from REBOA placement and the risk factors associated with injury and death among these patients at our institution.

METHODS

We performed a retrospective cohort study of all patients who underwent REBOA placement between September 2017 and June 2022 at our Level 1 Trauma Center. The primary outcome variable was the presence of an injury related to REBOA insertion or use. Secondary outcomes studied were limb loss, the need for dialysis, and mortality. Data were analyzed using descriptive statistics, χ2, and t-tests as appropriate for the variable type.

RESULTS

We identified 99 patients who underwent REBOA placement during the study period. The mean age of patients was 43.1 ± 17.2 years, and 67.7% (67/99) were males. The majority of injuries were from blunt trauma (79.8%; 79/99). Twelve of the patients (12.1%; 12/99) had a vascular injury related to REBOA placement. All but one required intervention. The complications included local vessel injury (58.3%; 7/12), distal embolization (16.7%; 2/12), excessive bleeding requiring vascular consult (8.3%; 1/12), pseudoaneurysm requiring intervention (8.3%; 1/12), and one incident of inability to remove the REBOA device (8.3%; 1/12). The repairs were performed by vascular surgery (75%; 9/12), interventional radiology (16.7%; 2/12), and trauma surgery (8.3%; 1/12). There was no association of age, gender, race, and blunt vs penetrating injury to REBOA-related complications. Mortality in this patient population was high (40.4%), but there was no association with REBOA-related complications. Ipsilateral limb loss occurred in two patients with REBOA-related injuries, but both were due to their injuries and not to REBOA-related ischemia.

CONCLUSIONS

Although vascular complications are not unusual in REBOA placement, there does not appear to be an association with limb loss, dialysis, or mortality if they are addressed promptly. Close coordination between vascular surgeons and trauma surgeons is essential in patients undergoing REBOA placement.

Thigh compartment syndrome: Outcomes in an urban level 1 trauma center

INTRODUCTION

Thigh compartment syndrome (TCS) is a rare surgical emergency associated with a high risk of morbidity with mortality rates as high as 47 %. There is sparse literature discussing the management as well as outcomes of these injuries. The purpose of this study is to review a consecutive series of patients presenting to a single urban Level 1 trauma center with TCS to identify injury characteristics, clinical presentation, and outcomes associated with this injury.

METHODS

A trauma database was queried for all patients with a diagnosis of TCS at a single level 1 urban trauma center between January 1, 2011 and December 31, 2021. Demographic and injury variables collected included age, sex, BMI, mechanism of injury, and creatine phosphokinase levels (CPK). Hospital quality measures including time from admission to surgery, length of both hospital and ICU stay, complications, and cost of care were collected. Descriptive statistics are reported as median [interquartile range] or N (percent).

RESULTS

There were 14 patients identified with a diagnosis of TCS. All were men with an average age 33.5 [23.5 - 38] years and an average BMI of 26 [22.9-28.1]. The most common cause of injury was blunt trauma (71.4 %), and the remaining 28.6 % were gunshot wound injuries. Within the cohort, 6 (42.9 %) patients sustained a femoral shaft fracture, and 4 (28.6 %) patients sustained a vascular injury. The median initial CPK of patients within this cohort was 3405 [1232-5339] and reached a peak of 5271 [3013-13,266]. The median time from admission to diagnosis was 6.8 [0-236.9] hours. The median time from admission to the operating room was 8.2 [0.6-236.9] hours, and the median number of operating room visits was 3 [2 - 6]. Five patients (35.7 %) wounds were closed with split thickness skin grafting. There were 12 (85.7 %) patients who required ICU care. The median ICU length of stay was 7.5 days [4-15]. The median hospital length of stay was 16.5 days [13.25-38.0]. The median total charges for a patient with thigh compartment syndrome was $129,159.00 [$24,768.00 - $587,152.00]. The median direct variable cost for these patients was $86,106.00 For comparison, the median direct variable cost for patients with femur fractures without TCS at this institution was $8,497.28 [$1,903.52-$21,893.13]. No patients required readmission within 60 days. There were no mortalities.

CONCLUSION

TCS is a rare and life-threatening injury associated with significant morbidity. Despite rapid diagnosis and fasciotomy, the majority of the patients have prolonged hospital courses, ICU lengths of stay, and significant costs of treatment. Providers can reference the outcomes reported in this study when caring for TCS patients.

Endothelial dysfunction and cardiovascular risk in post-COVID-19 patients after 6- and 12-months SARS-CoV-2 infection

INTRODUCTION

SARS-CoV-2 infection causes severe endothelial damage, an essential step for cardiovascular complications. Endothelial-colony forming cells (ECFCs) act as a biomarker of vascular damage but their role in SARS-CoV-2 remain unclear. The aim of this study was to assess whether the number of ECFCs and angiogenic biomarkers remained altered after 6 and 12-months post-infection and whether this imbalance correlated with the presence of long-COVID syndrome and other biological parameters measured.

METHODS

Seventy-two patients were recruited at different time-points after overcoming COVID-19 and thirty-one healthy controls. All subjects were matched for age, gender, BMI, and comorbidities. ECFCs were obtained from peripheral blood and cultured with specific conditions.

RESULTS

The results confirm the presence of a long-term sequela in post-COVID-19 patients, with an abnormal increase in ECFC production compared to controls (82.8% vs. 48.4%, P < 0.01) that is maintained up to 6-months (87.0% vs. 48.4%, P < 0.01) and 12-months post-infection (85.0% vs. 48.4%, P < 0.01). Interestingly, post-COVID-19 patients showed a significant downregulation of angiogenesis-related proteins compared to controls indicating a clear endothelial injury. Troponin, NT-proBNP and ferritin levels, markers of cardiovascular risk and inflammation, remained elevated up to 12-months post-infection. Patients with lower numbers of ECFC exhibited higher levels of inflammatory markers, such as ferritin, suggesting that ECFCs may play a protective role. Additionally, long-COVID syndrome was associated with higher ferritin levels and with female gender.

CONCLUSIONS

These findings highlight the presence of vascular sequela that last up to 6- and 12-months post-infection and point out the need for preventive measures and patient follow-up.

Management of vascular injuries on ICU patients: KZN experience

BACKGROUND

Vascular injury management remains an extremely challenging task. The fundamental principles of management are bleeding arrest and flow restoration, to avoid death and amputation. With advances in medicine, there has been a shift from ligation to primary repair which has resulted in a fall in amputation rate from 50 % in World War II to less than 2 % in civilian injuries.

METHOD

A retrospective cross-sectional study was conducted on ICU requiring polytrauma patients with vascular trauma admitted between January 2013 and December 2021. Additional data were collected prospectively from January 2022 to December 2022. All data was from an ethics approved Trauma Registry. The injury was either confirmed by imaging or via exploration. The pre-designed data proforma acquired the following variables: age, mechanism of injury, injured vessel, associated injury, management of the vessel, and management of the associated injury. The data were analysed using Stata version 17 (StataCorp, College Station TX). Frequencies and percentages were calculated to summarise numerical data An ethical clearance was granted by the University of KwaZulu-Natal BREC (BREC 0004353/2022) and the KZN Department of Health. All data were de-identified in the data collection sheet.

RESULTS

There were 154 arterial injuries and 39 venous injuries. The majority, 77 (50 %) of arterial injuries were managed via open strategies, and 36 (23 %) were managed via endovascular intervention. The majority, 20 (51 %) of venous injuries underwent open ligation, and 12 (31 %) were managed non-surgically. The highest number of endovascular interventions was observed in aortic injuries. For a total of 25 aortic injuries, 22 (83 %) were managed endovascular (TEVAR) and 2 (8 %) were managed non-operatively.

CONCLUSION

The choice between the endovascular and open approach depends on the injured blood vessel. The majority of venous injuries were treated with open ligation in this cohort.

Incidence of vascular injury associated with knee arthroplasty: series of cases

INTRODUCTION

The incidence of vascular injury associated with knee arthroplasty is scarce, but, when they occur, the consequences are serious.

OBJECTIVES

Describe the incidence of vascular lesions in our center and evaluate time to diagnosis, resolution and follow-up.

MATERIALS AND METHODS

Retrospective cohort during the 2010-2019 period of primary arthroplasties and knee revision. The incidence of vascular lesions and their demographic characteristics were analyzed. Type of lesion, diagnostic method and treatment were recorded. It was evaluated in distant follow-up of pain and functionality.

RESULTS

7.940 primary total knee arthroplasty and revision surgeries were recorded, and a report of 7 emergency cases for vascular lesions was also recorded, with an incidence of 0.088%. 3 vascular lesions were caused by direct laceration of the popliteal artery, 1 case of thrombosis of the popliteal artery and 3 cases of pseudoaneurysmal lesion of the superior genicular artery. Three vascular lesions that occurred in primary arthroplasty were immediately repaired by a vascular surgeon. Pseudoaneurysm lesions and thrombosis were resolved by angiographic procedure.

DISCUSSION

Vascular complications around the knee are rare. Time to diagnosis and treatment is essential. Digital angiography is a diagnostic and therapeutic tool. There are various repair techniques, whether it's embolization, cauterization, stenting or endoprosthesis; therefore, digital angiography is a safe method with a low complication rate.

CONCLUSION

The incidence of vascular lesions in knee arthroplasty in our center is very low. The cases were diagnosed and resolved early, without registering subsequent complications with good functional results in distant follow-up.

Macro- and microscopic changes in veins with short-term central venous catheters: an observational autopsy study

BACKGROUND

Centrally inserted central catheters (CICCs) are indispensable in modern healthcare, but unfortunately, come with complications. Catheter-related thrombosis is a well-known complication reported to occur in 5-30% of patients with CICC. There is a paucity of studies that report the incidence of catheter-related thrombosis after the introduction of real-time ultrasound insertion guidance as clinical practice. This study aimed to demonstrate any pathological macro- or microscopic changes in the vein wall associated with CICCs.

METHODS

The study was approved by the Swedish Ethical Review Authority and was conducted at a large university hospital. The study included 12 patients with a short-term CICC who were subject to autopsies. Vessels with inserted catheters were macroscopically and microscopically examined.

RESULTS

In total, seven female and five male patients with a median age of 70 (interquartile range 63-76) were included. With one exception, all patients received routine thromboprophylaxis throughout the period with CICC. Most inserted CICCs were 9.5 French (54%) and were inserted in the internal jugular vein (92%). The median time with CICC was seven days (interquartile range 1.8-20). At autopsy, thrombi were observed in all cases (100%), macroscopically and microscopically, attached to the distal portion of the CICC and/or the adjacent vessel wall. Inflammatory changes in the vessel walls were seen in all cases, and varying degrees of fibrosis were demonstrated in eight cases (67%).

CONCLUSIONS

This autopsy study demonstrated that catheter-related thrombus formation with adjacent inflammatory and fibrotic vessel wall thickening was very common, despite a limited period of catheter use. The consequences of these findings are important, as thrombi may cause pulmonary embolism and possibly lead to catheter-related infections, and since inflammatory and fibrotic vessel wall thickening may evolve into chronic venous stenosis. Furthermore, the findings are a cause of concern, as CICCs are indispensable in modern healthcare and complications may be masked by the general disease that was the indication for CICC insertion.

Open injuries and obesity as emerging risk factors for vascular injury in knee dislocations: A retrospective study

PURPOSE

Knee dislocations (KDs) are rare in orthopaedic trauma but can have devastating effects. Failing to diagnose a concomitant vascular injury can lead to amputation. Different methods are used for the diagnosis of a vascular injury and the best approach is under debate. This study aims to examine the risk factor(s) of vascular injury in patients with KDs, examine variables that differ between obese patients and non-obese patients with KDs, and analyse the modalities used to identify vascular injuries in the KD population.

METHODS

The electronic patient medical record system at a major trauma centre was retrospectively reviewed to identify knee dislocations from 2015 to 2022. These were stratified based on age, gender, BMI, mechanism of injury, vascular injury, non-vascular complications, and laterality. Co-variates were inputted into a univariable regression analysis, followed by a multivariable regression analysis to identify risk factors of vascular injury in patients with knee dislocations. Co-variates were also compared between obese and non-obese patients using two-tailed t-tests for continuous variables and chi-squared test for categorical variables.

RESULTS

Forty patients were identified with a KD, with twenty-eight males and twelve females. The average age was 42.9 years, seventeen patients had a BMI of thirty or over, and eleven patients (27.5%) had a vascular injury. Open injuries (OR: 2.21; 95% CI: 1.19-11.30; p = 0.038) and obesity (OR: 2.66; 95% CI: 1.45-18.69; p = 0.027) are risk factors for vascular injury in patients with knee dislocation. Compared to non-obese patients, obese patients had a higher rate of open injury (p = 0.028), vascular injury (p = 0.017), low-energy injuries (p = 0.014), non-vascular complications (p = 0.017), and amputation (p = 0.036).

CONCLUSION

Open injuries and obesity are risk factors for vascular injury in patients with KD. Compared to non-obese patients, obese patients have low-energy injuries and an increased rate of non-vascular complications, meaning that clinicians could err on the side of caution when investigating vascular injury.

LEVEL OF EVIDENCE

IV.

Dectin1 contributes to hypertensive vascular injury by promoting macrophage infiltration through activating the Syk/NF-κB pathway

Vascular injury is an early manifestation leading to end-organ damage in hypertension pathogenesis, which involves a macrophage-associated immune response. Dendritic cell-associated C-type lectin-1 (Dectin1) is a pivotal player in regulating inflammation-mediated cardiovascular disease. However, its role in hypertension-induced vascular damage and the underlying mechanisms remain unclear. We hypothesized that Dectin1 might accelerate angiotensin II (Ang II)- or deoxycorticosterone acetate-salt (DOCA-salt)-induced vascular injury through proinflammatory actions in macrophages. Macrophage Dectin1 was upregulated in mouse aortic tissues stimulated with Ang II. In the peripheral blood, Ang II also increased CD11b+F4/80+ macrophages in mice. In our constructed Dectin1 knockout mice, Dectin1 deletion protected against Ang II-induced EB extravasation and aortic wall thickness. Deficiency of Dectin1 or its pharmacological inhibition considerably improved fibrosis and inflammation responses, accompanied by a reduction in M1 macrophage polarization as well as proinflammatory cytokines and chemokines induced by Ang II or DOCA-salt. Through the bone marrow (BM) transplantation assay, these effects were verified in the wild type mice reconstituted with Dectin1-deficient BM cells. Mechanistically, Ang II promoted Dectin1 homodimerization, thereby triggering the spleen tyrosine kinase/nuclear factor kappa B pro-inflammatory cascade to induce the expression of inflammatory factors and chemokines in vivo and in vitro. In conclusion, Dectin1 has an essential role in the pathogenic procedure of Ang II-stimulated or DOCA-salt-induced vascular damage in mice and represents a promising therapeutic target for cardiovascular diseases.

Angio-Jet Thrombolysis for Traumatic Inferior Vena Cava Thrombosis; Case Report and Review of Literature

Background

Inferior vena cava thrombosis (IVC-Th) is a rare clinical entity after blunt abdominal trauma. It has both diagnostic and therapeutic dilemmas. Pulmonary embolism is the most dreadful complication and the leading cause of mortality after IVC-Th. Therefore, accurate prompt diagnosis is crucial.

Objective

The aim of this article was to present a case of IVC-Th in a young male patient who had a blunt traumatic abdominal injury after a motor vehicle accident.

Case presentation

The patient was brought to emergency department and was successfully managed by angio-jet thrombolysis. He developed a transient contrast nephropathy that was recovered after continuous renal replacement therapy. Several management options have been proposed in the literature, including conservative, endovascular and operative management.

Conclusion

Angio-jet is a recent promising technique for managing of venous thrombosis. However, its use in cases of IVC-Th is not extensively discussed in the literature.

Role of advanced glycation end products in diabetic vascular injury: molecular mechanisms and therapeutic perspectives

BACKGROUND

In diabetic metabolic disorders, advanced glycation end products (AGEs) contribute significantly to the development of cardiovascular diseases (CVD).

AIMS

This comprehensive review aims to elucidate the molecular mechanisms underlying AGE-mediated vascular injury.

CONCLUSIONS

We discuss the formation and accumulation of AGEs, their interactions with cellular receptors, and the subsequent activation of signaling pathways leading to oxidative stress, inflammation, endothelial dysfunction, smooth muscle cell proliferation, extracellular matrix remodeling, and impaired angiogenesis. Moreover, we explore potential therapeutic strategies targeting AGEs and related pathways for CVD prevention and treatment in diabetic metabolic disorders. Finally, we address current challenges and future directions in the field, emphasizing the importance of understanding the molecular links between AGEs and vascular injury to improve patient outcomes.

Cinematic rendering in the evaluation of complex vascular injury of the lower extremities: how we do it

Lower extremity trauma is one of the most common injury patterns seen in emergency medical and surgical practice. Vascular injuries occur in less than one percent of all civilian fractures. However, if not treated promptly, such injuries can lead to ischemia and death. Computed tomography angiography (CTA) is the non-invasive imaging gold standard and plays a crucial part in the decision-making process for treating lower extremity trauma. A novel, FDA-approved 3D reconstruction technique known as cinematic rendering (CR) yields photorealistic reconstructions of lower extremity vascular injuries depicting clinically important aspects of those injuries, aiding in patient workup and surgical planning, and thus improving patient outcomes. In this article, we provide clinical examples of the use of CR in evaluating lower extremity vascular injuries, including the relationship of these injuries to adjacent osseous structures and overlying soft tissues, and its role in management of lower extremity trauma.

Tartary buckwheat protein-derived peptide AFYRW alleviates H2O2-induced vascular injury via the PI3K/AKT/NF-κB pathway

Tartary buckwheat protein-derived peptide (Ala-Phe-Tyr-Arg-Trp, AFYRW) is a natural active peptide that hampers the atherosclerosis process, but the underlying role of AFYRW in angiogenesis remains unknown. Here, we present a system-based study to evaluate the effects of AFYRW on H2O2-induced vascular injury in human umbilical vein endothelial cells (HUVECs). HUVECs were co-incubated with H2O2 for 2 h in the vascular injury model, and AFYRW was added 24 h in advance to investigate the protective mechanism of vascular injury. We identified that AFYRW inhibits oxidative stress, cell migration, cell invasion, and angiogenesis in H2O2-treated HUVECs. In addition, we found H2O2-induced upregulation of phosphoinositide 3-kinase (PI3K), protein kinase B (AKT), phosphorylation of nuclear factor-κB (NF-κB) p65 and nuclear translocation of NF-κB decreased by AFYRW. Taken together, AFYRW attenuated H2O2-induced vascular injury through the PI3K/AKT/NF-κB pathway. Thereby, AFYRW may serve as a therapeutic option for vascular injuries.

Traumatic segmental renal infarction due to renal apical artery thrombosis by minor blunt abdominal trauma: the role of CEUS

Post-traumatic segmental renal infarction is an extremely rare event, especially in case of minor blunt abdominal trauma. While major trauma guidelines are well established, several problems account for the adequate management of minor trauma. Herein, we report a case of minor blunt abdominal trauma determining traumatic thrombosis of the apical renal artery and segmental renal infarction, firstly diagnosed by CEUS in emergency care setting.

ASC/Caspase-1-activated endothelial cells pyroptosis is involved in vascular injury induced by arsenic combined with high-fat diet

Environmental arsenic (As) or high-fat diet (HFD) exposure alone are risk factors for the development of cardiovascular disease (CVDs). However, the effects and mechanisms of co-exposure to As and HFD on the cardiovascular system remain unclear. The current study aimed to investigate the combined effects of As and HFD on vascular injury and shed some light on the underlying mechanisms. The results showed that co-exposure to As and HFD resulted in a significant increase in serum lipid levels and significant lipid accumulation in the aorta of rats compared with exposure to As or HFD alone. Meanwhile, the combined exposure altered blood pressure and disrupted the morphological structure of the abdominal aorta in rats. Furthermore, As combined with HFD exposure upregulated the expression of vascular endothelial cells pyroptosis-related proteins (ASC, Pro-caspase-1, Caspase-1, IL-18, IL-1β), as well as the expression of vascular endothelial adhesion factors (VCAM-1 and ICAM-1). More importantly, we found that with increasing exposure time, vascular injury-related indicators were significantly higher in the combined exposure group compared with exposure to As or HFD alone, and the vascular injury was more severe in female rats compared with male rats. Taken together, these results suggested that the combination of As and HFD induced vascular endothelial cells pyroptosis through activation of the ASC/Caspase-1 pathway. Therefore, vascular endothelial cells pyroptosis may be a potential molecular mechanism for vascular injury induced by As combined with HFD exposure.

Surgical management of distal humerus gunshot fractures: descriptive case series

PURPOSE

The purpose of this study was to report our 5 years surgical experience and the rate of neurovascular injury following gunshot fractures of the distal humerus in a in level-1 Trauma Centre in South Africa.

METHODS

A retrospective case series of 25 consecutive adult gunshot injuries to the distal humerus. Demographic and injury data were extracted from clinical case notes and electronic operative records. Imaging archives were used to classify fractures according to the AO/OTA classification.

RESULTS

Twenty-five male patients, with mean age of 32-years-old, sustained gunshot injuries to the distal humerus. Eleven patients had multiple gunshots. Forty-four percent of patients underwent Computed Tomography Angiography (CTA), 20% had confirmed brachial artery injury. Limbs with vascular injury were salvaged with arterial repair and external fixation. Fractures were extra-articular in 20 cases (80%). Nineteen fractures were classified as highly comminuted. Nerve injuries occurred in 52% and were all managed expectantly. Only 32% of patients attended follow-up beyond 3 months.

CONCLUSIONS

These are rare challenging injuries with high rates of neurovascular damage. This demographic of patients is poorly compliant with follow up highlighting the need for high-quality early care. Brachial artery injury should be excluded with CTA and can be managed with arterial repair and external fixation. All fractures in this series were surgically managed with conventional anatomical plate and screw fixation techniques. For nerve injury, we advocate expectant management.

LEVEL OF EVIDENCE

IV.

Complex pelvic fracture with massive hemorrhage in low resource settings: Case report

Pelvic fractures can range from simple, requiring almost no therapy, to complex, mandating the attention of the orthopedic surgeon, trauma surgeon, interventional radiologist, or other specialists because they are associated with multisystem injury and life-threatening hypotension. We present a 16-year-old male who presented with a complex pelvic fracture following a motor vehicle accidents that did not survive despite the efforts in resuscitation. In complex pelvic fracture with hemodynamic instability (hypotension persevered) and high index suspicion of bladder injury, there is an immediate need for operative intervention, regardless of negative/positive FAST (Focused Assessment with Sonography in Trauma).

Long-Term Exposure to Fine Particulate Constituents and Vascular Damage in a Population with Metabolic Abnormality in China

AIM

To date, PM2.5-associated vascular damage in metabolic abnormalities has remained controversial. We knew little about the vascular damage of PM2.5 constituents. Thus, this study aimed to investigate the relationship between long-term exposure to PM2.5 and its constituents and vascular damage in metabolic abnormalities.

METHODS

A total of 124,387 participants with metabolic abnormalities (defined as at least one metabolic disorder, such as obesity, elevated blood pressure, elevated triglyceride level, elevated fasting glucose level, or low HDL cholesterol level) were recruited in this study from 11 representative centers in China between January 2011 and December 2017. PM2.5 and its constituents (black carbon [BC], organic matter [OM], sulfate [SO42-], nitrate [NO3-], and ammonium salts [NH4＋]) were extracted. Elevated brachial-ankle pulse wave velocity (baPWV) (≥ 1,400 cm/s) and declined ankle-brachial index (ABI) (＜0.9) indicated vascular damage. Multivariable logistic regression and Quantile g-Computation models were utilized to explore the impact on outcomes.

RESULTS

Of the 124,387 participants (median age, 49 years), 87,870 (70.64%) were men. One-year lag exposure to PM2.5 and its constituents was significantly associated with vascular damage in single pollutant models. The adjusted odds ratios (OR) for each 1-µg/m3 increase in PM2.5 was 1.013 (95% CI, 1.012-1.015) and 1.031 (95% CI, 1.025-1.037) for elevated baPWV and decreased ABI, respectively. PM2.5 constituents were also associated with vascular damage in multi-pollutant models. Among the PM2.5 constituents, BC (47.17%), SO42- (33.59%), and NH4＋ (19.23%) have the highest contribution to elevated baPWV and NO3- (47.89%) and BC (23.50%) to declined ABI.

CONCLUSION

Chronic exposure to PM2.5 and PM2.5 constituents was related to vascular damage in the abnormal metabolic population in China. The heterogeneous contribution of different PM2.5 constituents to vessel bed damage is worthy of attention when developing targeted strategies.

A Novel Sutureless Anastomotic Device in a Swine Model: A Proof of Concept Study

INTRODUCTION

Vascular reconstruction requires technical expertise and is often time consuming. As a novel alternative to traditional hand-sewn vascular anastomoses, the VasoLock (VL), is a nonabsorbable, sutureless anastomosis device with traction anchors designed to hold free artery ends together. These anchors do not penetrate the vessel wall but adhere by leveraging the elasticity of the vessels to fasten blood vessels together. This pilot study assesses the performance and patency of this novel device in a porcine model of femoral artery injury.

METHODS

Female swine (n = 7) underwent femoral artery exposure for a total of 10 VL implanted. Study animals underwent hemodilution to a target hematocrit of 15% and ROTEM was used to assess coagulopathy, followed by an arterial injury via transection. The VL was inserted without any sutures. Flow-probe monitors were positioned proximal and distal to the device and flow rates were measured continuously for a total of 90 min. Flow was analyzed and presented as a ratio of distal to proximal flow with the slope of this ratio across time subsequently determined. Angiographic assessment was completed to evaluate for patency and technical complications after 90 min of implant.

RESULTS

The average animal weight was 44.1 ± 3.2 kg. The average mean arterial pressure at the time of implant was 51.2 ± 7.8 mmHg, median heart rate was 77.4 (IQR = 77.25-157.4) beats per minute, and average temperature was 36.1 ± 1.5°C. The baseline hematocrit was 13.5 ± 3.0%, average pH was 7.20 ± 0.1, average clotting time was 154.1 ± 58.7 s and average clot formation time was 103.4 ± 10.9 s all demonstrating the acidotic, hypothermic, and coagulopathic state of the swine at the time of insertion. During the 90-min observation period, the average flow gradient identified across the VL was 0.99 ± 0.24, indicating no significant change in flow across the VL. The average slope of the gradients was 0.0005 (P = 0.22), suggesting the ratio of proximal and distal flow did not change over the 90 min. Following 90 min of dwell time, all VL were patent without technical complication. Angiographic assessment at 90 min demonstrated no evidence of dissection, device migration, arterial extravasation, or thromboembolism with any of the 10 devices.

CONCLUSIONS

This pilot study demonstrated technical feasibility of the novel VL device over a 90-min observation period. All VL were patent and no negative events or complications were identified. This technology demonstrated significant promise in a coagulopathic state: additional investigation, involving long-term survival, is warranted for further validation.

Prevention of Pernicious Vascular Event: Acetabular Component Screw Impinging on External Iliac Vessels - A Unique Case Report

Introduction

Revision total hip arthroplasty requires meticulous planning and execution to achieve the desired outcome. Pelvic vessel injury following total hip arthroplasty is rare, but a well-known and serious complication, having a very high morbidity (15%) and mortality (7%). This case demonstrates the rare occurrence of acetabular screw abutment to the external iliac vessels, which if removed during revision hip surgery without releasing the adhesions around it, will lead to avulsion injury of the vessels and a catastrophic event.

Case Report

We present this challenging and unique case of a 64-year-old female patient where the acetabular component screw was found to be adherent to the external iliac vessels, with vascular injury imminent. During revision surgery, the iliac vessels were first released free of all adhesions with the intrapelvis screw using an ilioinguinal incision and retroperitoneal approach. The prosthesis was removed using a posterior approach to the hip joint. Definitive surgery was performed after 2 weeks.

Conclusion

Surgeons should be cognizant of the possibility of an avulsion vascular injury in revision cases having intrapelvic screws or implants. The proximity of such an implant with the intrapelvic vasculature must be confirmed preoperatively. Management should be individualized. Dual approach and staged procedure help in a favorable outcome. Vascular injury, revision total hip arthroplasty, screw abutting iliac vessel, external iliac vessel, computed tomographic angiography.

Immediate identification and management of an open posterior knee dislocation: Important lessons from a case report

Traumatic knee dislocation represents a rare event, contributing to less than 0.02 % of all orthopedic trauma and 0.05 % of joint dislocations, respectively. It is critically important to recognize, identify, and appropriately manage such cases as 'time' is implicated as an outcome-determining factor. Thus, such cases warrant quick consideration and appropriate management to mitigate the possibility of neurovascular damage and long-term sequelae. We report a case of a 59-year-old man struck by a motor vehicle in a remote rural community in northern Mexico managed with external fixation 16 h after the initial trauma, and later resulting in a supracondylar amputation. The authors of this case report underline the importance of timely intervention strategies when faced with such cases of knee dislocation and promote enhanced training of peripheral trauma-care providers to help improve patient outcomes.

ATP purinergic receptor signalling promotes Sca-1+ cell proliferation and migration for vascular remodelling

AIMS

Vascular resident stem cells expressing stem cell antigen-1 (Sca-1⁺ cells) promote vascular regeneration and remodelling following injury through migration, proliferation and differentiation. The aim of this study was to examine the contributions of ATP signalling through purinergic receptor type 2 (P2R) isoforms in promoting Sca-1⁺ cell migration and proliferation after vascular injury and to elucidate the main downstream signalling pathways.

METHODS AND RESULTS

ATP-evoked changes in isolated Sca-1⁺ cell migration were examined by transwell assays, proliferation by viable cell counting assays and intracellular Ca²⁺ signalling by fluorometry, while receptor subtype contributions and downstream signals were examined by pharmacological or genetic inhibition, immunofluorescence, Western blotting and quantitative RT-PCR. These mechanisms were further examined in mice harbouring TdTomato-labelled Sca-1⁺ cells with and without Sca-1⁺-targeted P2R knockout following femoral artery guidewire injury. Stimulation with ATP promoted cultured Sca-1⁺ cell migration, induced intracellular free calcium elevations primarily via P2Y₂R stimulation and accelerated proliferation mainly via P2Y₆R stimulation. Enhanced migration was inhibited by the ERK blocker PD98059 or P2Y₂R-shRNA, while enhanced proliferation was inhibited by the P38 inhibitor SB203580. Femoral artery guidewire injury of the neointima increased the number of TdTomato-labelled Sca-1⁺ cells, neointimal area and the ratio of neointimal area to media area at 3 weeks post-injury, and all of these responses were reduced by P2Y₂R knockdown.

CONCLUSIONS

ATP induces Sca-1⁺ cell migration through the P2Y₂R-Ca²⁺-ERK signalling pathway, and enhances proliferation through the P2Y₆R-P38-MAPK signalling pathway. Both pathways are essential for vascular remodelling following injury. Video Abstract.

Management and outcomes of firearm-related vascular injuries

BACKGROUND

Violence due to firearms is a major global public health issue and vascular injuries from firearms are particularly lethal. The aim of this study was to analyse population-based epidemiology of firearm-related vascular injuries.

METHODS

This was a retrospective nationwide epidemiological study including all patients with firearm injuries from the national Swedish Trauma Registry (SweTrau) from January 1, 2011 to December 31, 2019. There were 71,879 trauma patients registered during the study period, of which 1010 patients were identified with firearm injuries (1.4%), and 162 (16.0%) patients with at least one firearm-related vascular injury.

RESULTS

There were 162 patients admitted with 238 firearm-related vascular injuries, 96.9% men (n = 157), median age 26.0 years [IQR 22-33]. There was an increase in vascular firearm injuries over time (P < 0.005). The most common anatomical vascular injury location was lower extremity (41.7%) followed by abdomen (18.9%) and chest (18.9%). The dominating vascular injuries were common femoral artery (17.6%, 42/238), superficial femoral artery (7.1%, 17/238), and iliac artery (7.1%, 17/238). Systolic blood pressure (SBP) < 90 mmHg or no palpable radial pulse in the emergency department was seen in 37.7% (58/154) of patients. The most common vascular injuries in this cohort with hemodynamic instability were thoracic aorta 16.5% (16/97), femoral artery 10.3% (10/97), inferior vena cava 7.2% (7/97), lung vessels 6.2% (6/97) and iliac vessels 5.2% (5/97). There were 156 registered vascular surgery procedures including vascular suturing (22%, 34/156) and bypass/interposition graft (21%, 32/156). Endovascular stent was placed in five patients (3.2%). The 30-day and 90-day mortality was 29.9% (50/162) and 33.3% (54/162), respectively. Most deaths (79.6%; 43/54) were within 24-h of injury. In the multivariate regression analysis, vascular injury to chest (P < 0.001) or abdomen (P = 0.002) and injury specifically to thoracic aorta (P < 0.001) or femoral artery (P = 0.022) were associated with 24-h mortality.

CONCLUSIONS

Firearm-related vascular injuries caused significant morbidity and mortality. The lower extremity was the most common injury location but vascular injuries to chest and abdomen were most lethal. Improved early hemorrhage control strategies seem critical for better outcome.

Pseudoaneurysm - A Late and Rare Occurrence Following Shoulder Arthroscopy

Introduction

The incidence of vascular injuries from arthroscopic surgeries has been reported to be 0.005%. Pseudoaneurysms account for 11% of those injuries.

Case Report

In this case report, we discuss a 76-year-old female who presented with a pulsatile swelling in the right shoulder after 10 years following arthroscopic rotator cuff repair. Imaging confirmed the diagnosis of a posterior circumflex artery pseudoaneurysm. The patient was successfully embolised using a transradial approach with thrombosis of the pseudoaneurysm.

Conclusion

Vascular injuries following arthroscopic shoulder surgery are rare. However, a pseudoaneurysm should be considered in patients who present with swelling at the surgical site, regardless of the post-operative interval.

The anatomical feasibility of anterior intra- and extra-bifurcation approaches to L5-S1: an anatomic study based on lumbar MRI

BACKGROUND CONTEXT

The anterior approach at L5-S1 has many advantages, however, vascular complications are challenging for spinal surgeons who may not be familiar with the variability of vascular anatomy. There are three different anterior approaches (intra-bifurcation approach and extra-bifurcation: left-, and right-sided prepsoas approaches) described in previous studies to respond to the variability of anterior vascular anatomy for reduction in vascular injury, while no guidance for the choice of approach preoperatively.

PURPOSE

To analyze the anatomical feasibility of three anterior approaches to access the L5-S1 disc space according to a practical framework.

STUDY DESIGN

Retrospective study.

PATIENT SAMPLE

Lumbar magnetic resonance imaging (MRI) from patients who visited our outpatient clinic were reviewed, with 150 cases meeting the inclusion criteria.

OUTCOME MEASURES

The following radiographic parameters were measured on axial T2-weighted MRI at the lower endplate of L5 and the upper endplate of S1: width of the vascular corridor, position of the left and right common iliac vein (CIV), and presence of perivascular adipose tissue (PAT). Moreover, we designed a safe line to evaluate the feasibility of left- and right-sided prepsoas approaches. Cases of lumbosacral transitional vertebrae were identified.

METHODS

The feasibility of the intra-bifurcation approach was determined by the width of the vascular corridor, presence of PAT, and the position of the CIV. The feasibility of the prepsoas approach was determined by the relative position of the CIV to the safe line, presence of PAT, and the intersection point of the CIV and vertebral body.

RESULTS

Sixty-eight percent, 64.7%, and 75.3% cases allowed the intra-bifurcation, left-, and right-sided prepsoas approach to L5-S1, respectively. The cases in this study had at least one of three anterior approaches to access L5-S1 disc space, and 74% of cases had more than one anatomical feasibility of anterior approach. The right-sided prepsoas approach was feasible in the majority of cases because of the vertical course of the right CIV with a significantly higher proportion of presence of PAT. Patients with lumbosacral transitional vertebrae (24 cases) may prefer the prepsoas approaches, and only six cases (25.0%) were determined to be feasible for the intra-bifurcation approach.

CONCLUSIONS

Our study proposes a practical framework to determine whether the three different anterior approaches are feasible access at L5-S1. According to the framework, all cases had the anatomical feasibility of using an anterior approach to access L5-S1, and three-fourths of cases had a replaceable anterior approach when encountering intraoperative difficulties.

Managing the Patient with Peripheral Vascular Disease before Total Knee Arthroplasty Surgery

Peripheral vascular disease (PVD), defined as decreased arterial perfusion to the lower extremities due to atherosclerotic obstruction, is known to occur in patients undergoing total knee arthroplasty with described rates of between 2% and 4.5% PVD is of significance for patients undergoing TKA as it can increase wound healing and infection complications after TKA and is an independent risk factor for arterial complications following TKA. Our goal is to provide a comprehensive review of the pathophysiology of PVD as it relates to TKA, associated outcomes of patients undergoing TKA in the setting of PVD, diagnostic pearls, and current management strategies recommended in the published literature.

A Prospective Study of Management of Neck Trauma and its Complications : An Institutional Approach

Background: Assessment and immediate surgical management of laryngotracheal injuries is essential to minimize the risk of perioperative and long term complications [1]. The present study was conducted at tertiary care centre to assess the proportions of complications following neck injuries. Methodology: The study was conducted as a prospective study on 19 patients presenting with laryngotracheal injuries at Emergency department in NSCB Medical College, Jabalpur, India during the study period of 2 years. History was obtained in detail and depending upon the extent and nature of injury, patients were managed. Patients were followed up till discharge for assessment of any postoperative complications. Results: A total of 19 cases with neck trauma were enrolled during our study period with mean age of 27.37±8.88 years. Tracheal breach was noted in 78.9% cases. The most common site of airway injury was tracheal wall (47.3%), followed by Laryngeal trauma with unilateral or bilateral thyroid cartilage (15.8%). Major vessels injury was noted in 26.3% cases and injury to minor blood vessels was observed in 68.4% cases. Wound exploration followed by wound repair was done in 36.8% of the cases whereas emergency tracheostomy along with wound repair was done in 31.6% of the cases. During surgery, brachial plexus injury and surgical site infection were the surgical complications in 1 case each. However, anemia psychiatric tendency and symptoms due to alcohol withdrawal were the complications in 1 case each. Among postoperative complications, persistence of psychiatric symptoms, recurrent laryngeal nerve palsy, withdrawal symptoms, and complications due to brachial plexus injury persisted. Conclusion: Neck injuries and laryngotracheal injuries are rare but life threatening injuries, timely management of which is essentially important to avoid the occurrence of complications. Management often requires multidisciplinary approach due to associated complications. The complications may be immediate or remote which can be prevented if patients are managed timely.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-03533-7.

Vascular Injuries in Head and Neck Trauma

Blunt and penetrating vascular injuries of the head and neck can represent life-threatening emergencies that require accurate detection to prevent devastating and long-lasting consequences. Implementing appropriate screening criteria to indicate imaging studies is crucial as there is a variable latent time before the onset of clinical manifestations. Computed tomography angiography, MR imaging, and digital subtraction angiography represent the imaging modalities of choice to evaluate vascular injuries. The aim of this review is to provide a description of the different types of vascular injuries, describe the importance of each imaging modality, and recognize the imaging appearance of traumatic vessel injury.

Blunt Vascular Trauma in the Lower Extremity at a Major Trauma Centre: Salvage Rate and Complications

Introduction

Blunt trauma of the lower limb with vascular injury can cause devastating outcomes, including loss of limb and even loss of life. The primary aim of this study was to determine the limb salvage rate of patients sustaining such injuries when treated at Leeds General Infirmary (LGI) since becoming a Major Trauma Centre (MTC). The secondary aim was to establish patient complications.

Methods

A retrospective analysis found that from 2013 to 2018, 30 patients, comprising of 32 injured limbs, were treated for blunt trauma to the lower limb associated with vascular injury.

Results

Twenty-four patients were male and six were female. Their mean ages were 32 and 49, respectively. Three limbs were deemed unsalvageable and underwent primary amputation; of the remaining 29 potentially salvageable limbs, 27 (93%) were saved. Median ischaemic times for both amputees and salvaged limbs were under 6 hours. Of the 32 limbs, 27 (84%) were salvaged. All amputees had a MESS score ≥ 7, although not all patients with MESS ≥ 7 required amputation. Eleven limbs had prophylactic fasciotomies, three limbs developed compartment syndrome - all successfully treated and three contracted deep infections - one of which necessitated amputation. All but one patient survived their injuries and were discharged from the hospital.

Conclusion

Attempted salvage of 27/29 (93%) limbs was successful and all but one patient survived these injuries when treated at an MTC. MESS scoring and ischaemic time are useful but not sole predictors of limb salvage. Complication rates are low but may be significant for their future implications.

How to cite this article

Barnard L, Karimian S, Foster P, et al. Blunt Vascular Trauma in the Lower Extremity at a Major Trauma Centre: Salvage Rate and Complications. Strategies Trauma Limb Reconstr 2023;18(2):87-93.

Training in vascular trauma surgery for non-vascular surgeons: Vascular trauma surgery skills course

Background

The experience of general and trauma surgeons in vascular trauma management has decreased with sub-specialization of surgery and working hours restrictions. We introduce a vascular trauma surgery skills course established to train German military surgeons prior to their deployment to conflict areas.

Methods

The intention and implementation of the vascular trauma course for non-vascular surgeons is described in detail.

Results

In hands-on courses, participants learn and train basic vascular surgical techniques on more realistic extremity, neck, and abdominal models with pulsatile vessels. A fundamental and an advanced course each provide military as well as civilian surgeons from different non-vascular specialties with a surgical skill set including direct vessel sutures, patch angioplasty, anastomosis, thrombectomy, and resuscitative endovascular balloon occlusion of the aorta (REBOA) in order to render them capable of managing major vascular injuries.

Conclusion

The experiences of this vascular trauma surgical skills course, initially established for military surgeons, can also be of use to all civilian general, visceral, and trauma surgeons occasionally facing traumatic or iatrogenic vascular injuries. Thus, the introduced vascular trauma course is valuable for all surgeons working in trauma centers.

Vascular injury during laparoscopic cholecystectomy: An often-overlooked complication

Laparoscopic cholecystectomy is one of the most frequently performed procedures in gastrointestinal surgery worldwide. Bleeding complications due to vascular injuries represent an important cause of morbidity and mortality, especially when facing major bleeding during laparoscopy, where bleeding control can be technically challenging in inexperienced hands. Interestingly, the reported incidence rate of conversion to open surgery due to vascular lesions is approximately 0%-1.9%, with a mortality rate of approximately 0.02%. The primary aim of this article was to perform an up-to-date overview regarding the incidence and surgical management of vascular injuries during laparoscopic cholecystectomy according to the available scientific evidence.

Late deep femoral artery injury after intertrochanteric hip fracture treatment: A case report

INTRODUCTION AND IMPORTANCE

Arterial injury is a rare complication following hip fracture surgery. If not diagnosed appropriately, can lead to life- or limb-threatening situations. This report describes a case of late iatrogenic arterial injury, four weeks following surgery for intertrochanteric fracture.

CASE PRESENTATION

An 89-year-old woman suffered an intertrochanteric fracture. The deep femoral artery was injured four weeks after fracture treatment by dynamic hip screw, following increase of range of motion during the rehabilitation exercises. Pain and swelling increased markedly at the thigh. Slight fever with no tachycardia and the deceptive laboratory tests directed us to late-appearing sepsis. A color Doppler ultrasonography examination did not identify the arterial bleeding. Treatment was carried out to evacuate the presumed pus, but big clots were seen instead, and an active arterial bleeding was discovered. The arterial lesion was sutured and hemodynamic stability was restored.

CLINICAL DISCUSSION

The appearance of injury may be either acute or delayed. Unexplained laboratory results, use of beta-blockers and non-classical symptoms may be obstacles to early diagnosis of arterial injury.

CONCLUSION

A high index of clinical suspicion of arterial injury, even after long period after surgery, should be kept in mind. More precise investigations may be needed, as angiography, for making the diagnosis of arterial injury.

Continuous positive airway pressure for treating hypoxemia due to pulmonary vein injury: A case report

BACKGROUND

Vascular injury during thoracoscopic surgery for esophageal cancer is a rare but life-threatening complication that can lead to severe hypotension and hypoxemia. Anesthesiologists need to provide rapid and effective treatment to save patients' lives.

CASE SUMMARY

A 54-year-old male patient was scheduled to undergo a thoracoscopic-assisted radical resection of esophageal cancer through the upper abdomen and right chest. While dissociating the esophagus from the carina through the right chest, unexpected profuse bleeding occurred from a suspected pulmonary vascular hemorrhage. While the surgeon attempted to achieve hemostasis, the patient developed severe hypoxemia. The anesthesiologist implemented continuous positive airway pressure (CPAP) using a bronchial blocker (BB), which effectively improved the patient’s oxygenation and the operation was completed successfully.

CONCLUSION

CPAP using a BB can resolve severe hypoxemia caused by accidental injury of the left inferior pulmonary vein during surgery.

Vascular injury arising from lateral skull base fractures

PURPOSE

Although uncommon, vascular injury can be seen in patients with lateral skull base fractures (LSBF). However, little is known about this potentially life-threatening comorbidity. The objective of this study is to better characterize the vascular injuries associated with temporal and lateral sphenoid bone fractures.

BASIC PROCEDURES

Retrospective review of all patients with computed tomography angiography (CTA) performed specifically to evaluate for vascular injury following LSBF. In addition to patient demographics (age, gender, race), the mechanism of injury, the location of fracture(s), and the nature of vascular injury diagnosed by CTA was recorded. Two-way ANOVA was performed to determine if any variables were predictive of vascular injury.

MAIN FINDINGS

From 2011 to 2021, 143 patients with 333 subsite fractures met inclusion criteria. Of all patients, 46 (32.2 %) had CTA evidence of at least one vascular injury, the most common type being venous thrombosis/filling defect (41.7 %). Evidence of vascular injury was unclear in 14 patients (9.8 %). Fractures most associated with vascular injury ranged from 0.7 % (otic capsule fractures) to 26.7 % (mastoid, lateral sphenoid fractures). Risk of vascular injury was no different between patients with single vs multiple fractures. There were no fracture locations that could reliably predict specific vascular injury.

CONCLUSIONS

Over 40 % of all CTAs ordered following LSBF identified were suspicious for associated vascular injury. Yet fracture location and number cannot reliably predict vascular injury. Until such determinants can be better identified, clinicians should have a low threshold to obtain CTA to rule out associated vascular injury.

Caveolin-1 alleviates acetaminophen-induced vascular oxidative stress and inflammation in non-alcoholic fatty liver disease

Acetaminophen (APAP) is one of the most widely used drugs in the world. The literature shows that excessive or long-term use of APAP can lead to increased cardiovascular dysfunction. An acute increase in angiotensin Ⅱ (Ang Ⅱ) caused by APAP use in fatty liver disease may increase the risk and severity of vascular injury. However, the underlying mechanism remains unclear. Caveolin-1 (CAV1) is a broad-spectrum kinase inhibitor that significantly determines endothelial function. This study aimed to observe the effects of APAP on the vasculature in non-alcoholic fatty liver disease (NAFLD) and to determine whether CAV1 could alleviate vascular oxidative stress and inflammation by targeting Ang Ⅱ or its downstream pathways. In this study, 7-week-old C57BL/6 male mice (18-20 g) were administered APAP by gavage after eight weeks of a high-fat diet. Any resulting vascular oxidative stress and inflammation were assessed. Levels of Ang Ⅱ, CAV1, and other related proteins were measured using ELISA and western blotting. In APAP-treated NAFLD mice, CAV1 expression was downregulated and Ang Ⅱ expression was upregulated compared to normal APAP-treated mice. In vitro, HUVECs were incubated with Ang Ⅱ (300 nM) for 48 h. Overexpression of CAV1 in HUVECs attenuated Ang Ⅱ-induced oxidative stress and inflammation and downregulated the expression of Protein kinase C (PKC) and p-P38/P38. After intervention with CAV1-siRNA, immunofluorescence results showed that the fluorescence intensity of PKC on mitochondria was further increased, and flow cytometry results showed that the mitochondrial membrane potential increased. PKC inhibitors alleviated Ang Ⅱ-induced endothelial injury. In conclusion, our findings confirmed that CAV1 exerts a protective effect against vascular injury by inhibiting oxidative stress and inflammation through the PKC/MAPK pathway. Therefore, restoration of CAV1 may have clinical benefits in reducing APAP-induced vascular damage in NAFLD patients.

Vascular injury is associated with repetitive head impacts and tau pathology in chronic traumatic encephalopathy

Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease linked to repetitive head impacts (RHI) and characterized by perivascular hyperphosphorylated tau (p-tau) deposits. The role of vascular injury, blood-brain barrier leakage, and neuroinflammation in CTE pathogenesis is not well understood. We performed quantitative immunoassays for intercellular adhesion molecule 1 (ICAM1), vascular cellular adhesion molecule 1 (VCAM1), and C-reactive protein (CRP) within the postmortem dorsolateral frontal cortex of participants with and without a history of RHI and CTE (n = 156), and tested for associations with RHI, microgliosis, and tau pathology measures. Levels of vascular injury-associated markers ICAM1, VCAM1, and CRP were increased in CTE compared to RHI-exposed and -naïve controls. ICAM1 and CRP increased with RHI exposure duration (p < 0.01) and were associated with increased microglial density (p < 0.001) and tau pathology (AT8, p-tau396, p-tau202; p < 0.05). Histologically, there was significantly increased ICAM1 staining of the microvasculature, extracellular space, and astrocytes at the sulcal depths in high stage CTE compared to both low stage CTE and controls. Multifocal perivascular immunoreactivity for serum albumin was present in all RHI-exposed individuals. These findings demonstrate that vascular injury markers are associated with RHI exposure, duration, and microgliosis, are elevated in CTE, and increase with disease severity.

A case of inferior phrenic artery injury after chest drainage treated laparoscopically

Chest drainage is a commonly performed surgical procedure. However, caution is required when performing this procedure because of its serious complications. One complication is vascular injury. Endovascular treatment has been prioritized in patients requiring hemostasis. We report the case of an 87-year-old woman, who presented to our hospital with dyspnea caused by massive pleural effusion. We decided to perform chest tube placement for the purpose of diagnosis and treatment. The inferior phrenic artery was injured during chest drainage, resulting in hemorrhagic shock. Catheter embolization was considered, but it was deemed difficult due to the patient's abnormal blood vessel. Instead, hemostasis was induced via laparoscopy. This is the first report on the safety of laparoscopic hemostasis for inferior phrenic artery bleeding. By devising, we were able to perform hemostatsis safely under laparoscopy.

Incidence of vascular lesions associated with disruption of the bile duct secondary to cholecystectomy

BACKGROUND

One of the most serious complications of cholecystectomy is bile duct disruption, which can be associated with concomitant vascular injury in up to 3.4%. The incidence, demographic characteristics and treatment are underreported worldwide.

OBJECTIVE

To determine the incidence of vascular lesions in patients with a diagnosis of bile duct disruption secondary to cholecystectomy from January 1, 2015 to December 31, 2019, confirmed by preoperative CT angiography or intraoperative findings.

METHOD

Retrospective, observational and analytical study of a series of cases between 2015 and 2019. Where a total of 144 cases of bile duct disruption were found, 15 cases (10%) with concomitant vascular injury.

RESULTS

The most frequent vascular injury was of the right hepatic artery in 13 patients (87%). The level of biliary disruption most frequently associated was Strasberg E3 and E4 in 5 patients (36%), respectively. The treatment of vascular injury was ligation of the injured vessel in 11 patients (73%). The treatment established for the repair of biliary disruption was the hepatic jejunum anastomosis in 14 patients (93%).

CONCLUSIONS

The presence of injury at the level of the right hepatic artery is the most frequent and its ligation did not show a significant impact on biliodigestive reconstruction, as long as an adequate technique is performed (Hepp-Couinaud).

Vascular Injury During Lumbar Disc Surgery: Case Report

A retroperitoneal organ injury-vascular injury or solid organ injury-that occurs during lumbar disc surgery needs to be dealt with adequately, because otherwise it could result in a poor (or, even, fatal) outcome of a "simple" procedure. Vascular injuries require special attention from the neurosurgical side (think of the possibility!) and cooperation between neurosurgeons and abdominal/vascular surgeons. In the presented case of a very obese female patient, a bite injury of the aorta during L3/4 disc surgery led to delayed intra-abdominal hemorrhage, which then required an emergency abdominal operation followed by major thromboembolic complication, and ultimately resulted in amputation of the patient's healthy leg. Pitfalls in intraoperative diagnosis and postoperative care are discussed, along with related medicolegal issues.

Avoidance of Pitfalls and Complications During Surgery for Temporal Lobe Epilepsy

Anterior temporal lobectomy with amygdalohippocampectomy is the most common epilepsy surgery, which, in cases of mesial temporal lobe epilepsy caused by mesial temporal sclerosis, usually leads to improvements in seizure control, cognitive function, and quality of life. Nevertheless, while the primary goal of intervention is achieved in a large majority of patients, a small number of them, unfortunately, encounter complications. Some morbidity is nonspecific and may be noted after any craniotomy (e.g., surgical site infections, meningitis, bone flap osteomyelitis, and operative site or craniotomy-related hematomas). On the other hand, certain complications are specifically associated with surgery for temporal lobe epilepsy and can be discussed from the etiological standpoint: mechanical injuries of the brain; injury of eloquent neuronal structures; arterial and venous injuries; cerebral venous thrombosis; remote cerebellar hemorrhage; and postoperative hydrocephalus, seizures, and psychiatric disorders. In many cases, these complications are manifested in the early postoperative period by alterations of consciousness and a focal neurological deficit, and it may require immediate decisions on their appropriate management.

Complication Avoidance in Spine Surgery

The outcomes of spine surgery are closely related to postoperative morbidity. Therefore, an experienced surgeon must be aware of various complications and should apply all necessary preventive measures to avoid them. It is widely considered that complications of spine surgery are underreported and that their real incidence is much higher than expected. This review highlights methods to prevent various types of morbidity that may be encountered during different spinal procedures, considering general complications, approach-related complications, fusion- and implant-related complications, and systemic complications.

Endovascular Management of a Basilar Artery Pseudoaneurysm After Iatrogenic Injury During Endoscopic Third Ventriculostomy: Case Report

Endoscopic third ventriculostomy (ETV) is a well-established neurosurgical procedure. However, it carries risks of intraoperative complications, among which major vascular injury is the most dangerous. Reportedly, prominent bleeding during ETV has been noted in <1% of cases. Herein, we describe a case of a 34-year-old woman with occlusive hydrocephalus caused by a quadrigeminal cistern arachnoid cyst, who developed a pseudoaneurysm after injury of the basilar artery apex during ETV. Complete obliteration of the pseudoaneurysm with endovascular balloon-assisted coiling was done on the first postoperative day, and the patient demonstrated gradual recovery, but approximately 4 weeks later, she suffered massive rebleeding, seemingly due to rupture of the weak pseudoaneurysm wall, which resulted in her death. Careful evaluation of sagittal T2-weighted magnetic resonance images before ETV may be invaluable for assessment of the basilar artery position in relation to the third ventricle floor. In addition, use of a blunt surgical instrument (instead of a sharp one or cautery) for fenestration may be safer for prevention of arterial injury. Finally, special care should be applied in cases with an opaque third ventricle floor and inability to visualize the basilar artery during ETV.

Acetabular Screw in Close Proximity to the Posterior Branch of the Internal Iliac Artery in Revision Hip Surgery with Intrapelvic Migration of Acetabular Component: Preoperative Placement of a Fogarty Catheter in the Internal Iliac Artery (Case Report)

Revision of an intrapelvic migration of the acetabular component of a total hip is a challenging surgery due to the risk of injury to the pelvic viscera. The primary concern is vascular injury due to the risk of mortality and limb loss. The researchers present one case where the acetabular screw was near the posterior branch of the internal iliac artery. A Fogarty catheter was placed in the internal iliac artery preoperatively, and the amount of fluid to inflate the catheter and completely block the artery was determined. The catheter was kept in a deflated condition. The hip reconstruction was performed, and there was no incidence of vascular injury during the procedure; hence, the Fogarty catheter was removed postsurgery. The placement of a Fogarty catheter in the at-risk vessel provides the freedom to proceed with the hip reconstruction through the standard approach. In case of an inadvertent event of a vascular injury, it can be inflated with the predetermined amount of saline to check the bleeding until the vascular surgeons take over the case.

Intraoperative and early postoperative complications of reverse shoulder arthroplasty: A current concepts review

Background

Reverse shoulder arthroplasty is a common procedure performed for a variety of shoulder pathologies.

Aims and objectives

This current concept review evaluates the intraoperative and early postoperative complications, with a specific focus given to neurological and vascular injury, fracture, dislocation and venous thromboembolism.

Conclusion

A detailed knowledge of potential complications will allow surgeons to mitigate risk and maximise outcomes.

Silent iatrogenic pseudoaneurysm after intertrochanteric fracture fixation with proximal femoral nailing and cerclage wiring: case report and review of literature

Pseudoaneurysm is a rare complication after intertrochanteric fracture fixation. Herein, we present a rare case of late development of a pseudoaneurysm with silent clinical symptoms. The case was a 91-year-old woman treated with proximal femoral nailing and cerclage wiring. Postoperatively, the patient was able to ambulate with a walker without abnormal symptoms. During the follow-ups, the radiographic images showed progressive cortical scalloping on the medial femoral shaft. Ultrasonography revealed a yin-yang sign, and a CT scan confirmed a pseudoaneurysm at the profunda femoris artery (PFA). In this case, many possible causes of pseudoaneurysm were hypothesized. We showed that the excessive displaced, long spiral pattern of an intertrochanteric fracture, which was irreducible by a closed technique, is the risk of a PFA injury. An atherosclerotic vessel was seen in preoperative radiography, indicating poor vessel elasticity which may be a risk of vessel tear during fracture reduction using multiple reduction instruments in excessive displaced fracture. Moreover, over-penetration when drilling should not be overlooked. We also discuss the predisposing factors, surgical techniques which may lead to this type of PFA injury and summarize the literature of pseudoaneurysms related to intertrochanteric fracture fixation.

MKL1 fuels ROS-induced proliferation of vascular smooth muscle cells by modulating FOXM1 transcription

Reactive oxygen species (ROS) promotes vascular injury and neointima formation in part by stimulating proliferation of vascular smooth muscle cells (VSMC). The underlying transcriptional mechanism, however, is not completely understood. Here we report that VSMC-specific deletion of MKL1 in mice suppressed neointima formation in a classic model of vascular injury. Likewise, pharmaceutical inhibition of MKL1 activity by CCG-1423 similarly mollified neointima formation in mice. Over-expression of a constitutively active MKL1 in vascular smooth muscle cells enhanced proliferation in a ROS-dependent manner. On the contrary, MKL1 depletion or inhibition attenuated VSMC proliferation. PCR array based screening identified forkhead box protein M1 (FOXM1) as a direct target for MKL1. MKL1 interacted with E2F1 to activate FOXM1 expression. Concordantly, FOXM1 depletion ameliorated MKL1-dependent VSMC proliferation. Of interest, ROS-induced MKL1 phosphorylation through MK2 was essential for its interaction with E2F1 and consequently FOXM1 trans-activation. Importantly, a positive correlation between FOXM1 expression and VSMC proliferation was identified in arterial specimens from patients with restenosis. Taken together, our data suggest that a redox-sensitive phosphorylation-switch of MKL1 activates FOXM1 transcription and mediates ROS fueled vascular smooth muscle proliferation. Targeting the MK-2/MKL1/FOXM1 axis may be considered as a reasonable approach for treatment of restenosis.

How I do it: re-do surgery for recurrent trigeminal neuralgia

BACKGROUND

When trigeminal neuralgia recurs after microvascular decompression surgery, re-operation may be indicated if trigeminal nerve compression remains. However, surgery for recurrent trigeminal neuralgia is more difficult because of adhesions between the prosthesis, such as the Teflon sling, and the surrounding structures, including the blood vessels, in addition to common post-open surgery adhesions.

METHOD

A case of a patient with recurrent trigeminal neuralgia is presented.

CONCLUSION

Preoperative evaluation of the compression of the trigeminal nerve is important. The pre-existing prosthesis does not necessarily need to be removed entirely.