Left atrial compression syndrome secondary to coronary artery perforation: Pathophysiology, diagnosis, and management strategies.

Coronary perforation (CP) poses a significant risk of morbidity and mortality, particularly, in patients with a history of cardiac surgery. The occurrence of loculated pericardial effusion presents distinctive challenges in these postcardiac surgical patients. This study delves into the complexities arising from the formation of loculated pericardial effusions subsequent to CP, with a specific focus on the loculated effusion in the posterior wall leading to left atrial compression syndrome. This analysis is dedicated to elucidating pathophysiology diagnostic and treatment strategies tailored for addressing left atrium compression syndrome, providing invaluable insights into the intricacies of diagnosing, treating, and managing this entity in the postcardiac surgical patient.

Optimum Surgical Strategies for Medial Sphenoid Wing Meningiomas: A Comprehensive Evaluation of Resection Extent, Visual Outcomes, and Vascular Injury.

BACKGROUND/OBJECTIVE: Visual impairment affects 55%-80% of medial sphenoid wing meningiomas (mSWMs) patients, making optic nerve decompression a critical surgical goal. Complete resection often leads to better visual outcomes. However, involvement of critical neurovascular structures increases postoperative morbidity and mortality, with vascular injury reported in 18%-20% of cases. This study aims to evaluate the relationship between the extent of resection (EOR), visual outcomes, and the incidence of vascular injury, seeking to identify the optimal surgical approach for mSWMs. METHODS: We retrospectively analyzed data from patients undergoing surgery for mSWM at our tertiary care center from January 2001 to December 2021. Inclusion criteria included histopathologically confirmed globoid mSWMs (N = 89). Patients with recurrent tumors (n = 14) or lost to follow-up (n = 9) were excluded. We classified patients into 2 groups based on EOR using Simpson's grade: Group 1 (good-resection,Simpson Grade-I/II,n = 51) and Group 2 (poor-resection,Simpson Grade III/IV, n = 15). RESULTS: Among 66 (=N) patients, visual impairment was the most common symptom (81.8%), followed by headaches (77.3%) and seizures (27%). T2-hyperintensity on magnetic resonance imaging [(OR:5.4, 95%CI:1.5-18.6) (P-value<0.01)] and cavernous sinus-extension [(OR:3.9, 95%CI:1.1-13.1) (p-value-0.02)] were independent significant predictors of poor resection. Visual status was preserved in 90.3% of Group-1 and 86.6% of Group-2, with no significant difference based on EOR. Vascular involvement was noted in 87.9%, higher than the vessel encasement (>1800) (57.6%, P = 0.04). Vessel injury occurred in 7.8% of Group-1 and 6.6% of Group-2, with no significant impact on EOR. CONCLUSIONS: Cavernous sinus-extension and T2-hyperintensity predict poor resection rates in mSWMs. While visual outcomes are not directly affected by EOR, long-term visual status may decline due to tumor recurrence and radiotherapy. Vascular injury incidence is not associated with EOR. Thus, the "maximal safe resection" of mSWMs involves a surgical strategy balancing targeted aggressive and conservative resection for maximal cytoreduction and functional preservation.

Selective postmortem arterial angiography of head and neck using digital x-ray or computed tomography: A practical and rapid method to identify vascular injuries.

Identification of vascular injuries is crucial for complete postmortem evaluation and understanding of trauma deaths by the Medical Examiner. Some vascular injuries are difficult to evaluate due to challenging anatomic locations, especially in the head and neck. Documenting injuries of the facial and vertebral arteries is challenging and necessitates time-consuming dissections that can create artifacts and disfigurement. In busy medical examiner offices with a significant number of traumatic injuries, finding a creative solution to employ reliable postmortem angiography is desirable. At the Office of the Chief Medical Examiner for the State of Maryland (OCME), we created and effectively implemented a selective angiography procedure using traditional indwelling Foley catheters and water-soluble barium swallow contrast to evaluate arterial injuries using either digital radiography or computed tomography imaging modalities. This technique and imaging interpretation can be performed by a medical examiner or forensic pathology fellow after basic technical training and basic radiology training. This study outlines the technique, methods, and utilization of the procedure and describes the findings of six deaths due to vascular lesions from different injury mechanisms and disease processes and describes the ease of implementation on a broader scale in busy Medical Examiner's offices.

Single-Center Long-Term Results of Popliteal Artery Blunt Trauma Management Following Knee Dislocation - A Case Series Study.

BACKGROUND: Injury to the popliteal artery after knee dislocation, if not promptly diagnosed and properly treated, can have devastating results. The purpose of this retrospective study was to describe the diagnostic and the treatment protocol we use, as well as provide long-term outcomes for a series of patients treated in our tertiary hospital, emphasizing on the importance of ankle-brachial index (ABI) measurement as an integral component of the diagnostic approach. METHODS: A retrospective analysis of all admissions to our hospital trauma center between November 1996 and July 2023, with a diagnosis of knee dislocation and the presence or absence of concomitant arterial injury resulting from blunt high-energy trauma, was conducted. Before 2006, digital subtraction angiography (DSA) and/or computed tomography angiography (CTA) were part of the diagnostic approach (group A). After 2006, the ABI was used as a first-line test to diagnose arterial damage (group B). The Tegner and Lysholm scores were chosen to assess patients' postoperative impairment between groups, taking also into account the presence or absence of vascular injury. The Mann-Whitney U test and a univariate analysis of variance were used for the statistical analysis of scores. RESULTS: Overall, 55 patients were identified, and 21 of them (38.2%) had injuries to the popliteal artery, all of which were treated with a reversed great saphenous venous bypass. Out of the 21 patients, 4 (4.3%) developed compartment syndrome, which was treated with fasciotomies, and 1 leg (1.8%) was amputated above the knee. With no patients lost to follow-up, all but one (95%) of the vascular repairs are still patent, and the limbs show no signs of ischemia after a mean follow-up of 6 years. The Tegner and Lysholm score means were similar between groups A and B and independent of the presence of vascular injury and the diagnostic protocol used. Interestingly, an ABI below 0.9 proved to be predictive of arterial injury. CONCLUSIONS: A high level of awareness for the presence of popliteal artery injury should exist and an ABI measurement should be routinely performed in the management of all cases of knee dislocation. This way, fewer patients will undergo unnecessary CTA scanning, and hardly any popliteal artery injuries can go missing, as suggested by our study.

Long-Term Survival and Reintervention Following Thoracic Endovascular Aortic Repair in Blunt Traumatic Thoracic Aortic Injury: A Systematic Review and Meta-Analysis.

BACKGROUND: Blunt thoracic aortic injury (BTAI) represents one of the most devastating scenarios of vascular trauma. Different management strategies are available with varying clinical outcomes. However, thoracic endovascular aortic repair (TEVAR) has become the first-line option for most BTAI patients, mainly owing to its minimally invasive nature, yielding improved immediate results. This meta-analysis aims to investigate mortality, long-term survival, and reintervention following TEVAR in BTAI. MATERIAL AND METHODS: A systematic review conducted a comprehensive literature search on multiple electronic databases using strict search terms. Twenty-seven studies met the set inclusion/exclusion criteria. A proportional meta-analysis of extracted data was conducted using the Comprehensive Meta-Analysis Software, v.4. RESULTS: 1498 BTAI patients who underwent TEVAR were included. Using the SVS grading system, 2.6% of the population had Grade 1 injuries, 13.6% Grade 2, 62.2% Grade 3, 19.6% Grade 4, and 1.9% unspecific. All-cause mortality did not exceed 20% in all studies except one outlier with a 37% mortality rate. Using the random effects model, the pooled estimate of overall mortality was 12% (95% confidence interval [CI], 5.35-8.55%; I2 = 70.6%). This was 91% (95% CI, 88.6-93.2; I2 = 30.2%) at 6 months, 90.1% (95% CI, 86.7-92.3; I2 = 53.6%) at 1 year, 89.2% (95% CI, 85.2-91.8; I2 = 62.3%) at 2 years, and 88.1% (95% CI, 83.3-90.9; I2 = 69.6%) at 5 years. Moreover, the pooled estimate of reintervention was 6.4% (95% CI, 0.1-0.49%; I2 = 81.7%). CONCLUSIONS: Despite the high morbidity and mortality associated with BTAI, TEVAR has proven to be a safe and effective management strategy with favorable long-term survival and minimal need for reintervention. Nevertheless, diagnosis of BTAI requires a high index of suspicion with appropriate grading and prompt transfer to trauma centers with appropriate TEVAR facilities.

Identifying Risk Factors for Poor Outcomes Following Popliteal Vascular Injuries.

BACKGROUND: Popliteal artery injuries (PAIs) may have amputation rates as high as 20%. This study focuses on identifying risk factors associated with major amputations following PAIs in a large single-center cohort. Additionally, we assess the impact of repairing or ligating concomitant popliteal vein injuries. METHODS: A retrospective chart review encompassing 2011 to 2023 was conducted at a large urban level 1 trauma center. Patients with PAIs were included. Demographics and clinical data were analyzed, and univariate and multivariate evaluations identified significant risk factors for amputation. In patients with concomitant popliteal vein injuries, we compared outcomes between those who underwent popliteal vein repair and ligation. RESULTS: One hundred eighty eight patients with PAIs were identified; 10 underwent index amputation and were excluded. Univariate analysis followed by multivariate analysis revealed that obesity (P = 0.0132) and neurologic deficits on arrival (P = 0.0096) were associated with amputation. In the subgroup with popliteal vein injuries (N = 93), there was no significant difference in amputation rates between those who had vein repair (P = 0.21) and those who underwent ligation (P = 0.84) on logistic regression analysis. Likewise, popliteal vein ligation did not impact duration of fasciotomy closure (P = 0.20) or skin graft area (P = 0.48) based on linear regression analysis. CONCLUSIONS: Our study suggests that major amputations following PAIs are more likely in obese patients with neurologic deficits. It also suggests that venous ligation in cases of concomitant popliteal vein injuries does not significantly impact early limb salvage rate. Further research is needed to determine the optimal approach for managing concomitant popliteal vein injuries.

Hidden Inferior Vena Cava Injury: A Case of Missed Diagnosis after Preoperative CT and Laparotomy.

BACKGROUND Inferior vena cava (IVC) injury is a potentially fatal injury with a high mortality rate of 34-70%. In cases in which the patient's condition is stable, diagnosis by computed tomography (CT) is the criterion standard. Findings on CT include retroperitoneal hematoma around the IVC, extravasation of contrast medium, and abnormal morphology of the IVC. We report a case of an IVC injury that could not be diagnosed by preoperative CT examination and could not be immediately detected during laparotomy. CASE REPORT A 73-year-old woman had stabbed herself in the neck and abdomen at home using a knife. When she arrived at our hospital, we found a stab wound several centimeters long on her abdomen and a cut approximately 15 cm long on her neck. We activated the massive transfusion protocol because she was in a condition of hemorrhagic shock. After blood transfusion and blood pressure stabilization, contrast-enhanced computed tomography (CT) revealed a small amount of fluid in the abdominal cavity. An otorhinolaryngologist performed successful drainage and hemostasis, and a laparotomy was performed. Gastric injury and mesentery injury of the transverse colon were identified and repaired with sutures. Subsequent search of the retroperitoneum revealed massive bleeding from an injury to the inferior vena cava (IVC). The IVC was repaired. Postoperative progress was good, and she was discharged from the hospital 65 days after her injuries. CONCLUSIONS We experienced a case of penetrating IVC injury, which is a rare trauma. Occult IVC injury may escape detection by preoperative CT examination or during laparotomy.

Intravascular Ultrasound May Not Impact Graft Sizing in Endovascular Repair of Blunt Thoracic Aortic Injury.

OBJECTIVES: Thoracic endovascular aortic repair (TEVAR) is the preferred treatment for severe blunt thoracic aortic injuries (BTAI). Successful outcomes rely on accurate endograft sizing, but initial imaging may underestimate aortic diameters. This study examines the impact of intravascular ultrasound (IVUS) on endograft sizing and clinical outcomes in BTAI patients. METHODS: A prospectively collected multi-institutional dataset from the Aortic Trauma Foundation was analyzed. Patients with BTAI undergoing TEVAR with IVUS were compared to patients who underwent TEVAR alone. Demographics and operative variables were compared, focusing on IVUS effects on endograft sizing by examining maximal proximal and distal aortic diameter on initial CT imaging compared to the graft diameters used during TEVAR. RESULTS: 293 patients underwent TEVAR for BTAI with IVUS utilized in 124 cases (42.3%). The average graft size in the IVUS and non-IVUS groups were similar proximally (26.91 ± 4.3 mm IVUS vs 27.77 ± 4.7 mm non-IVUS, P = 0.116) and distally (25.96 ± 4.7 mm IVUS vs 26.51 ± 4.7 mm non-IVUS). IVUS did not impact the difference between graft size and initial CT measurements proximally (4.32 ± 4.8 mm IVUS vs 4.23 ± 3.9 mm non-IVUS, P = 0.859) or distally (4.17 ± 5.9 mm IVUS vs 4.50 ± 4.3 mm non-IVUS, P = 0.606). Although delayed hemorrhagic and ischemic stroke occurred less frequently in IVUS patients (0.8% IVUS vs 7.1% non- IVUS, P = 0.024), in-hospital mortality was similar between groups (5.6% IVUS vs 7.7% non-IVUS, P = 0.581). CONCLUSIONS: IVUS is not associated with significant changes in endograft sizing compared to sizing based on CT scan alone in BTAI patients. IVUS was not associated with differences in mortality but was associated with a decrease in delayed hemorrhagic and ischemic stroke. Routine IVUS in BTAI patients may not be necessary for accurate sizing, but there may be a relationship between IVUS and stroke.

Delayed femoral artery injury caused by heterotopic ossification: a rare case report and review of the literature.

BACKGROUND: Arterial injury caused by heterotopic ossification (HO) following fractures is rarely reported, yet it can have catastrophic consequences. This case report presents a unique instance of femoral artery injury and hematoma organization, occurring a decade after intramedullary nail fixation for a femoral shaft fracture complicated by HO. CASE PRESENTATION: A 56-year-old male presented with right femoral artery injury and organized hematoma, a decade after suffering bilateral femoral shaft fractures with mild head injury in a traffic accident. He had received intramedullary nailing for the right femoral shaft fracture and plate fixation for the left side in a local hospital. Physical examination revealed two firm, palpable masses with clear boundaries, limited mobility, and no tenderness. Peripheral arterial pulses were intact. Radiography demonstrated satisfactory fracture healing, while a continuous high-density shadow was evident along the inner and posterior aspect of the right thigh. Computed tomography angiography identified a large mixed-density mass (16.8 × 14.8 × 20.7 cm) on the right thigh's medial side, featuring central calcification and multiple internal calcifications. The right deep femoral artery coursed within this mass, with a smaller lesion noted on the posterior thigh. Surgical consultation with a vascular surgeon led to planned intervention. The smaller mass was completely excised, but the larger one partially, as it encased the femoral artery. The inability to remove all HO was due to excessive bleeding. Postoperatively, the patient experienced no complications, and one-year follow-up revealed a favorable recovery with restoration of full right lower limb mobility. CONCLUSION: This case underscores the potential gravity of vascular injury associated with heterotopic ossification. Surgeons should remain vigilant regarding the risk of vascular injury during HO excision.

Traumatic proximal tibiofibular fracture and dislocation.

BACKGROUND: Traumatic proximal tibiofibular fracture and dislocation (PTFD) have been rarely studied and are easily missed in clinical practice. PTFD is considered a marker of severely traumatized knees. The purpose of this study was to retrospectively analyze the incidence and impact of PTFD in traumatized knees with vascular injury. METHODS: Patients with knee trauma and vascular injury were included from January 2022 to October 2023. X-rays and CT scans of included patients were retrospectively analyzed to determine the presence of PTFD. Patients were further divided into PTFD group and non-PTFD group for further comparative analysis. RESULTS: A total of 27 patients (28 limbs) were included. Incidence of PTFD was 39.3% (11/28) in traumatic knee with vascular injury, including 8 anterolateral dislocations and 3 posteromedial dislocations. PTFD group had significantly more limbs with open injuries compared with non-PTFD group (10/11 VS 7/17, p<0.05). Amputation rate of PTFD group was as high as 40% (4/10), compared to 23.5% (4/17) in non-PTFD group. However, the difference between two groups was not statistically significant (p>0.05). CONCLUSIONS: PTFD was easily overlooked or missed. In traumatized knees with vascular injury, incidence of PTFD was high. The presence of PTFD might indicate severe knee trauma and the possibility of open injury. Although there was no significant difference compared with non-PTFD group, PTFD group had a relatively high amputation rate of 40%.

Management of Suspected Peripheral Vascular Injuries in Orthopedic Trauma.

OBJECTIVE: In orthopedic trauma, identification of extremity trauma combined with vascular injury is challenging. Missed diagnosis may result in amputation or even death. The purpose of this study was to investigate whether physical examination combined with handheld vascular ultrasound Doppler examination could be an effective method of screening for peripheral vascular injury and to explore the characteristics of vascular injuries in orthopedic trauma patients. METHODS: Retrospective analysis of patients in the emergency department of orthopedic trauma in our hospital from January 2022 to October 2023. Physical examination combined with handheld vascular ultrasound Doppler examination was used as a screening method for suspected vascular injuries. Patients with suspected vascular injury would undergo further angiography and receive multidisciplinary treatment. Angiography was used as the gold standard for diagnosing vascular injuries. Patient demographics, mechanism of injury, location and type of injury, angiographic results, surgical notes, and early treatment outcome data were recorded. RESULTS: A total of 55 cases (58 limb injuries) with suspected vascular injury were ultimately included. Angiography revealed that 53 cases (55 limbs, positive rate 94.8%) were considered to have confirmed vascular injuries. Forty-three were male (81.1%) and 10 were female (18.9%), with mean age 44.1 ± 16.6 years. The main mechanism of injury was traffic accident (30, 56.7%). Most common site of vascular injuries was knee joint (30/55, 54.5%), and popliteal artery (23, 47.9%) was the most commonly injured blood vessel. After multidisciplinary collaborative treatment, overall patient mortality was 3.8% (2/53), and limb survival rate among surviving patients was 81.1% (43/53) in our study. CONCLUSION: In orthopedic trauma, "Hard signs" and "soft signs" combined with handheld vascular ultrasound Doppler examination were effective ways to screen for suspected vascular injuries. Most limbs had associated fractures or dislocations at the site of vascular injury. Collaboration of vascular surgery, microsurgery and orthopedic trauma may help improve patients' prognosis.

The role of body mass index in high- and low-velocity trauma causing knee injury associated with popliteal artery lesions.

BACKGROUND: Among arterial traumas, osteoarticular traumas are particularly dangerous, and those involving the popliteal artery are associated with a high amputation rate. Despite representing a minority of arterial traumas, with an incidence that varies considerably by population and geographic location, traumatic lesions of the popliteal artery are challenging. This study aimed to verify the impact of body mass index (BMI) on arterial trauma damage and patient outcomes. METHODS: Data were retrospectively collected from the electronic medical reports of all patients with osteoarticular and vascular associated lesions treated in the emergency operating room at our institution between 1 January 2005 and 1 May 2022. Forty-one patients presented with lower limb arterial trauma (43.2%); popliteal artery lesions occurred in 11 of these patients (26.8%), who were eligible for inclusion in the study. The lesion mechanism was dislocation by high-velocity trauma in 9 patients and dislocation by low-velocity trauma in 3 patients. All 7 males (63.6%) experienced high-velocity trauma, and 2 of the 3 females experienced low-velocity trauma. Only one patient had an isolated popliteal artery lesion associated with fractures in the leg or the contralateral limb. Patients with low-velocity trauma were older than 54 years, while those with high-velocity trauma were aged 22 to 71 years. RESULTS: In 10/11 patients (90.9%), revascularization was performed after osteoarticular stabilization and reduction of the dislocation or fracture. Intraoperative angiography was selectively used. Two patients required above-the-knee amputation after the procedure: one due to infection of the surgical access point and the other due to severe soft tissue injury. One patient died during hospitalization due to trauma-related complications and comorbidities. CONCLUSIONS: High-velocity trauma and low-velocity trauma in patients with a body mass index > 35 kg/m2 and knee lesions are associated with popliteal artery lesions. Revascularization success is not associated with high- or low-velocity trauma.

Late coronary artery injury following chemoradiotherapy for thymic carcinoma: a case report.

INTRODUCTION: Surgery remains the primary treatment modality for thymic carcinoma, with adjuvant radiotherapy being recommended to effectively mitigate local recurrence and metastasis rates subsequent to incomplete or complete resection. Chemoradiotherapy has the potential to induce coronary artery occlusion, thereby potentially impacting patients' long-term survival rates. The existing literature currently lacks comprehensive research on the lesion characteristics of coronary artery injury resulting from chemoradiotherapy. CASE PRESENTATION: The male patient, aged 55, was admitted to the hospital due to recurrent chest tightness and pain persisting for one week. Notably, the patient had previously undergone curative resection surgery for thymic carcinoma seven years ago. After the surgical procedure, the patient underwent a course of adjuvant chemotherapy comprising docetaxel and platinum. 11 months later, imaging examination diagnosed tumor recurrence, and concurrent chemoradiotherapy was administered at a total dose of 62 Gy/31F for planning gross target volume (PGTV) and 54 Gy/31F for planning target volume (PTV) with 2 cycles of paclitaxel and cisplatin. Re-admission of the patient occurred after a 7-year interval subsequent to the completion of concurrent chemoradiotherapy, leading to a subsequent diagnosis of acute non-ST segment elevation myocardial infarction. Following administration of antiplatelet, anticoagulant, and anti-myocardial ischemia therapy, coronary angiography revealed the presence of a bifurcation lesion at the distal end of the left main trunk. Intravascular ultrasound (IVUS) examination demonstrated significant negative remodeling of both the main trunk and its branches at the bifurcation site, characterized by minimal atherosclerotic plaque components. CONCLUSIONS: Chemoradiotherapy may induce damage to endothelial cells, resulting in an inflammatory response. Negative remodeling of blood vessels is likely to occur, primarily characterized by vasoconstriction but with less atherosclerotic plaque burden. Routine stent implantation in negatively remodeled areas may lead to vascular rupture, necessitating intravascular imaging examination.

Increased Mortality in Patients Transferred to a Level 1 Trauma Center with Blunt and Penetrating Extremity Vascular Injuries.

BACKGROUND: Trauma care depends on a complex transfer system to ensure timely and adequate management at major trauma centers. Patient outcomes depend on the reliability of triage in local or community hospitals and access to tertiary or quaternary trauma institutions. Patients with polytrauma, extremity trauma, or vascular injuries require multidisciplinary management at trauma hospitals. Our study investigated outcomes in this population at a level one trauma center in San Bernardino County, the largest geographic county in the contiguous United States. METHODS: We conducted a retrospective review of all patients with extremity trauma who presented to a single level 1 trauma center over 10 years. The cohort was divided into following two groups: 1. transferred from another medical center for a higher level of care or 2. those who directly presented. Overall, 19,417 patients were identified, with 15,317 patients presenting directly and 3,830 patients transferred from an outside hospital. Extremity of vascular injuries was observed in 268 patients. Demographic data were ascertained, including the injury severity score, mechanism of injury, response level, arrival method, tertiary center emergency department disposition, and presence of vascular injury in the upper or lower extremities. Univariate and multivariate analyses were performed to assess patient mortality. RESULTS: A total of 268 patients with vascular injuries were analyzed, including 207 nontransferred and 61 transferred patients. In the univariate analysis, injury severity score means were compared at 11.4 in nontransferred patients versus 8.4 in transferred (P < 0.001), 50% of blunt injury in the nontransferred group, and 28% in the transferred group (P < 0.001); in-hospital mortality was 4% in nontransferred patients versus 28% in the transferred group (P < 0.001). Multivariate logistic regression demonstrated that mortality is 8 times more likely if a patient with vascular extremity injuries is transferred from an outside hospital. A 10% mortality rate was observed in patients without blood transfusion within 4 hr of arrival to the trauma center and 3% mortality in transferred patients transfused blood. CONCLUSIONS: Extremity trauma with vascular injury can be lethal if managed appropriately. Patients transferred to our level 1 trauma center had a substantial increase in mortality compared with nontransferred patients. Furthermore, the transfer distance was associated with increased mortality. Further research is required to address this vulnerable patient population.