The Impact of Blunt Thoracic Aortic Injury on Patients Aged 80 Years or Older

BACKGROUND

Blunt thoracic aortic injury (BTAI) is rare and associated with significant morbidity and mortality in trauma patients. As the population ages and life expectancy increases, the frequency of this injury will increase in the elderly and thus it behoves us to understand treatment and outcome in this patient population.

METHODS

We analysed prospectively collected data of 10 patients > 80 years old with BTAI (Group A) treated among 26,000 trauma patients over a 20-year period in a Level 1 trauma center to investigate BTAI morbidity and mortality. Age, gender, and injurity severity score (ISS) matching was performed to create a case-control study of elderly trauma patients with (Group A) and without BTAI (Group B).

RESULTS

Ten elderly trauma patients were found to have BTAI. Five (50%) were males and 5 (50%) were female. The cohort mean age was 86 years (range: 80 to 95). All but one patient (fall injury) were involved in motor vehicle accidents. The mean ISS in group A was 29 ± 12. In group A, 2 (20%) patients (ISS = 36 and 33) succumbed in the emergency department. Six (60%) patients were treated non-operatively and the remaining 2 (20%) patients (88 and 84 years) underwent open aortic repair with patch angioplasty and Dacron interposition grafting. No postoperative paraplegia or stroke related to surgery occurred. Two patients in Group A survived hospitalization and were eventually discharged. Patients in Group B had lower overall LOS, ICU LOS and 30-day mortality rates despite similar ISS.

CONCLUSION

Patients aged 80 or older who have experienced BTAI tend to have worse outcomes than those without BTAI regardless of similar ISS. Therefore, because of the low incident of this injury in general and particularly in the elderly, only pooled data from multiple institutions will be able to shed light on the complex issues surrounding treatment decisions in a group of patients with an a priori limited life expectancy.

Outcomes of endoscopically harvested saphenous vein for lower extremity bypass

OJECTIVES

The purpose of this study was to evaluate the outcomes of endoscopically harvested saphenous vein (EHSV) for lower extremity bypass (LEB) surgery.

METHODS

Data from 91 consecutive patients who underwent LEB using EHSV between February 2003 and November 2012 were analyzed. Outcomes of interest were wound infection, patency, re-intervention and limb loss.

RESULTS

Fifty-eight (64%) and 33 (36%) patients underwent femoropopliteal (FP) and femorotibial (FT) bypass using EHSV. Three (3%) patients had superficial and 1 (1%) deep wound infection. Primary and primary assisted patency at 5 years was 68% and 71% in the FP group and 56% and 65% in the FT group. Six (6%) patients underwent major amputation. No predicting factors for wound infection or graft patency were found.

CONCLUSIONS

EHSV carries a low incidence of perioperative wound complication and has a reasonable mid-to-long-term patency regardless of the length of vein harvested.

Diagnosis of venous disease with duplex ultrasound

The advent of duplex ultrasound (DU) has changed vascular practice over the years. Venous anatomy, valve function and obstruction can be evaluated in real time using DU. It is a low cost, portable, non-invasive, safe and operator-friendly device that can be used for diagnosis, treatment guidance and follow-up. This paper defines the patterns, location and characteristics of venous reflux and also provides insightful information on acute and chronic venous obstruction.

Re-modelling of venous thrombosis

Venous thromboembolism is one of the most common causes of morbidity and mortality in modern societies. The entirety of events involved in venous thrombus formation and resolution remains to be elucidated. Temporal relation between the initial cellular insult, thrombus formation and resolution is critical for instituting a prompt treatment. This paper analyses the current basic knowledge and the events involved in venous re-modelling after an episode of venous thrombosis.

Pattern and types of non-saphenous vein reflux

Venous reflux often originates from saphenous trunks and their tributaries. In about 10% of the patients reflux derived from non-saphenous veins (NSV) such as those located in the buttock, posterolateral thigh, vulva, lower posterior thigh, popliteal fossa, knee or along the peripheral nerves such as the tibial and sciatic nerve. It is also important to note that patients who had saphenous vein stripping or ablation have higher odds of presenting with NSV reflux. The majority of patients with NSV reflux have varicose veins and lower extremity oedema; however, about 10% of those patients present with skin damage. This paper analyses the patterns and types of NSV reflux for diagnosis and treatment purposes.

Phlebosclerosis in lower extremities veins

Objectives: To determine the prevalence, distribution and extent of phlebosclerosis in an outpatient population referred to vascular clinic.

Design: Prospective cohort study.

Patients and Methods: Seven hundred and forty consecutive patients, 302 (41%) men with a cohort median age of 49 (range, 18–84), were referred to the vascular clinic for detection of lower extremity acute or chronic venous disease. A total of 1000 limbs were assessed using duplex ultrasonography. Deep veins were not assessed. Characteristics of venous wall and lumen were studied. Phlebosclerosis was diagnosed based on the increased echogenicity and thickness or calcification of the venous wall. Patients with known trauma or any surgery in the lower extremities were excluded. Two control groups were used for comparison, one of consecutive patients undergoing vein mapping ( n = 100) and the other of younger volunteers free of any vein disease ( n = 25).

Results: Of the 1000 limbs (right: 458, left: 542) studied by duplex ultrasound, 21 limbs had intense brightness of the venous wall. Fifteen of them had also calcifications and 61 wall thickening. The prevalence of phlebosclerosis was significantly higher in the patient group when compared with control groups 1 (P = 0.019) and 2 (P = 0.011). The mean age of patients with phlebosclerosis was higher compared with the whole patient group (57 versus 49 years, P < 0.0001). Phlebosclerosis affected all superficial veins with greater prevalence in the small saphenous vein (SSV). The mean length of the phlebosclerotic lesion was 2 cm (range 1–7 cm).

Conclusion: The prevalence of phlebosclerosis in the lower extremities appears to be low with no significant sex differences. Age and chronic venous disease are important factors for its development. It may be present in the absence of thrombosis or reflux. A greater prevalence of phlebosclerotic lesions was found in the SSV.

pharmacomechanical Thrombectomy for Early Thrombus Removal

Objectives:

To review the current literature on the outcomes of pharmacomechanical thrombectomy (PMT) for early thrombus removal in patients with venous thromboembolism (VTE).

Methods:

We searched the MEDLINE database and performed a manual search of the references of selected articles to select reports reporting the outcomes of PMT alone and PMT compared to catheter-direct thrombolysis (CDT). Outcomes of interest included clot lysis rate, incidence of pulmonary embolism, major bleeding, recurrent deep vein thrombosis, number of venograms needed and amount of lytic utilized.

Results

We found nine articles that reported outcomes of PMT. Three devices were utilized for PMT, the Angiojet, Trellis and Helix. Different thrombolytics were used to facilitate thrombus removal including urokinase, reteplase, tecneteplase, and tissue plasminogen activator (t-PA). Complete and partial thrombus removal were achieved in up to 84% and 64% and 81% and 59% of the limbs treated with PMT and CDT alone, respectively. Data on PE and bleeding risk after PMT compared to CDT are scarce. The duration of the thrombolysis process, amount of lytics and number of venograms were substantially reduced in the patients who had PMT compared to those who underwent CDT alone. Two articles evaluated the obstacles that limit the indication of PMT in patients with VTE.

Conclusion:

VTE is a prevalent burden in Western societies. The rationale of early thrombus is to reduce valvular damage and improve venous patency in order to reduce the risk of PTS. PMT is a feasible, safe and faster alternative to expedite the thrombolysis process in patients with VTE.

Diagnosis and follow-up of varicose veins with duplex ultrasound: how and why?

Chronic venous disease (CVD) is very prevalent and causes a significant financial burden in Western societies. Accurate diagnosis is mandatory to define the anatomy and pathophysiology involved in the disease process. Duplex ultrasound (DU) is a well-established non-invasive tool used for varicose veins work-up that, most recently, has also been utilized for follow-up after endovenous procedures such as endovenous laser or radiofrequency ablation and foam sclerotherapy. Insightful information on how DU is performed during varicose veins work-up and the rationale of DU utilization for endovenous procedures are discussed.