Level One Trauma Center Proliferation May Worsen Patient Outcomes.

BACKGROUND: From 2013 to 2020, Arizona state trauma system expanded from seven to thirteen level 1 trauma centers (L1TCs). This study utilized the state trauma registry to analyze the effect of L1TC proliferation on patient outcomes. METHODS: Adult patients age≥15 in the state trauma registry from 2007-2020 were queried for demographic, injury, and outcome variables. These variables were compared across the 2 time periods: 2007-2012 as pre-proliferation (PRE) and 2013-2020 as post-proliferation (POST). Multivariate logistic regression was performed to assess independent predictors of mortality. Subgroup analyses were done for Injury Severity Score (ISS)≥15, age≥65, and trauma mechanisms. RESULTS: A total of 482,896 trauma patients were included in this study. 40% were female, 29% were geriatric patients, and 8.6% sustained penetrating trauma. The median ISS was 4. Inpatient mortality overall was 2.7%. POST consisted of more female, geriatric, and blunt trauma patients (P < .001). Both periods had similar median ISS. POST had more interfacility transfers (14.5% vs 10.3%, P < .001). Inpatient, unadjusted mortality decreased by .5% in POST (P < .001). After adjusting for age, gender, ISS, and trauma mechanism, being in POST was predictive of death (OR: 1.4, CI:1.3-1.5, P < .001). This was consistent across all subgroups except for geriatric subgroup, which there was no significant correlation. DISCUSSION: Despite advances in trauma care and almost doubling of L1TCs, POST had minimal reduction of unadjusted mortality and was an independent predictor of death. Results suggest increasing number of L1TCs alone may not improve mortality. Alternative approaches should be sought with future regional trauma system design and implementation.

Cavernous Malformations of the Optic Nerve and Optic Pathway: A Case Series and Systematic Review of the Literature.

BACKGROUND: Although rare, cavernous malformations (CMs) of the optic nerve and anterior optic pathway (optic pathway cavernous malformations [OPCMs]) can occur, as described in several single case reports in the literature. OBJECTIVE: To describe the technical aspects of microsurgical management of CMs of the optic pathway on the basis of an extensive single-center experience and review of the literature. METHODS: A systematic literature review was performed to augment an earlier review, using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. In addition, an institutional database was searched for all patients undergoing surgical resection of OPCMs. Patient information, surgical technique, and clinical and radiographic outcomes were assessed. RESULTS: Since the previous report, 14 CMs were resected at this institution or by the senior author at another institution. In addition, 34 cases were identified in the literature since the systematic review in 2015, including some earlier cases that were not discussed in the previous report. Most OPCMs were resected via pterional, orbital-pterional, and orbitozygomatic craniotomies. Visual outcomes were similar to those in earlier reports, with 70% of patients reporting stable to normal vision postoperatively. CONCLUSION: OPCMs can occur throughout the anterior visual pathway and may cause significant symptoms. Surgery is feasible and should be considered for OPCMs presenting to a surface of the nerve. Favorable results can be obtained with resection, although optimal results are obtained with patients who present with milder symptoms without longstanding damage to the optic apparatus.

Intraoperative pneumatic tourniquet use may improve the clinical outcomes of arteriovenous fistula creations.

OBJECTIVES: A major pathology affecting the usability of arteriovenous fistulas for hemodialysis is juxta-anastomosis stenosis. Intraoperative pneumatic tourniquet eliminates the use of vascular clamps, reduces vascular trauma, and may then reduce the juxta-anastomosis stenosis. The aim of this study was to compare the outcomes of arteriovenous fistula creations using the tourniquet-assisted approach versus the clamp-assisted approach. METHODS: This retrospective study analyzed the outcomes of primary arteriovenous fistulas created by the lead author from 2008 to 2017 and met the specified inclusion criteria applied to both groups. RESULTS: A total of 575 patients were included. Upon comparing the tourniquet group (n = 411) with the clamp group (n = 164): the primary arteriovenous fistula failure rate was significantly lower (2.4% vs 7.3%, p = 0.01); the percentage of arteriovenous fistula used for hemodialysis without initial interventions was significantly higher (71.5% vs 45.1%, p < 0.001) and with initial interventions was conversely lower (26.0% vs 47.6%, p < 0.001); the primary patency rate of the whole fistula conduits was significantly higher (44.2% vs 23.0% at 1 year, p < 0.001) and so was the cumulative patency rate (97.2% vs 92.6% at 1 year, p < 0.001); and the juxta-anastomosis primary patency rate (free of interventions for the juxta-anastomosis region) was higher (71.0% vs 47.8% at 1 year, p < 0.001). Based on multivariate Cox proportional hazards regression analyses, the effect of tourniquet use on the juxta-anastomosis primary patency remained significant (hazard ratio = 2.24, 95% confidence interval = 1.72-2.93, p < 0.001) when other significant factors (fistula location, gender, and diabetes) were considered. CONCLUSION: Intraoperative pneumatic tourniquet may significantly improve the clinical outcomes of arteriovenous fistula creations by reducing juxta-anastomosis trauma and subsequent stenosis.

Efficacy and comparison of elevation transposition and lipectomy for superficialization of cephalic arteriovenous fistula veins.

OBJECTIVE: Substantial percentages of cephalic arteriovenous fistulas are situated too deep and require superficialization before use for hemodialysis. The superficialization techniques are diverse: tunnel transposition, elevation, elevation transposition, and lipectomy. Since the fistula veins are not mobilized during lipectomy, it is believed that lipectomy produces better outcomes than other techniques. However, no available report directly compares lipectomy with other techniques. The objective of this report is to compare the outcomes of cephalic elevation transposition with lipectomy. METHODS: The clinical data of patients who underwent second-stage cephalic elevation transposition or lipectomy at an ambulatory surgery center from 2009 to 2017 were analyzed ( n = 153). RESULTS: Comparing the cephalic elevation transposition group ( n = 125) with the lipectomy group ( n = 28), the mean body mass index was 36.8 ± 7.6 versus 38.1 ± 7.2 ( p = 0.41); the percentage of upper arm fistulas was 84% versus 61% ( p < 0.01); the mean follow-up was 20.1 ± 17.5 versus 38.6 ± 24.4 months ( p < 0.01); the primary patency rates of the whole fistula conduits were 42% versus 50% at 1 year ( p = 0.08); the secondary patency rates were 99% versus 100% at 1 year ( p = 0.22); the primary patency rates of the superficialized vein segments were 73% versus 68% at 1 year ( p = 0.72); and the mean number of percutaneous interventions required for the superficialized vein segments was 0.49 ± 1.10 versus 0.43 ± 0.71 per access-year ( p = 0.74). CONCLUSION: Cephalic elevation transposition and lipectomy are both reliable techniques for superficialization of cephalic fistula veins and their outcomes are comparable.

Successful use of partial aneurysmectomy and repair approach for managing complications of arteriovenous fistulas and grafts.

OBJECTIVE: Arteriovenous fistulas and grafts may often be associated with localized complications related to aneurysms/pseudoaneurysms, buttonholes, or structural defects that require proper management to ensure continued access functionality for hemodialysis. Partial aneurysmectomy and repair (PAR) is a targeted surgical approach specifically designed for managing these complications. The basic concepts of PAR include resecting unhealthy or excessive tissue over an access, reconstructing the vascular access lumen using in situ vascular wall or tissue when possible, and closing overlying skin with healthy margins to promote reliable healing. This report analyzes the clinical outcomes of PAR in a large clinical series. METHODS: The demographic and outcome data of patients who underwent PARs at an ambulatory surgery center from 2009 to 2016 were collected and analyzed. RESULTS: A total of 220 PAR operations were performed in 209 patients, of which 185 had fistulas and 24 had grafts. In the fistula group, 11 patients underwent subsequent staged aneurysm repairs. Comparing the fistula group (n = 185) vs the graft group (n = 24): men were 63% vs 29%, the mean age was 60.1 ± 14.8 vs 63.9 ± 16.0 years, diabetic patients were 54% vs 75%, the mean age of the accesses at the time of repair was 5.3 ± 3.2 vs 5.0 ± 4.0 years, the upper arm accesses were 69% vs 88%, the forearm accesses were 31% vs 12%, and the mean follow-up was 27.9 ± 21.9 vs 14.0 ± 11.6 months. A pneumatic tourniquet was used during 81% of the fistula and 42% of the graft operations. Dialysis catheters were required in 2% of the patients in the fistula group and 4% in the graft group to continue hemodialysis. After repair operations, the primary patency, assisted primary patency, and secondary patency rates of the whole access conduit for the fistula group were 45%, 96%, and 98% at 1 year; 28%, 91%, and 96% at 2 years; and 19%, 87%, and 95% at 3 years, respectively. The same patency rates of the graft group were 31%, 70%, and 96% at 6 months and 10%, 57%, and 96% at 1 year, respectively. Two fistulas and one graft were lost ≤30 days postoperatively. CONCLUSIONS: PAR is a reliable approach for managing localized arteriovenous access complications related to aneurysms/pseudoaneurysms, buttonholes, or structural defects. Given its simplicity and reliability, we recommend PAR as a first-line choice for managing these complications of arteriovenous fistulas and a choice in selected arteriovenous graft patients.

Basilic elevation transposition may improve the clinical outcomes for superficialization of basilic arteriovenous fistula veins.

OBJECTIVE: Basilic vein arteriovenous fistulas are an important and common option for hemodialysis access and require superficialization before use. Various superficialization techniques have been employed, such as basilic tunnel transposition (BTT), basilic elevation, and basilic elevation transposition (BET). Each technique may have advantages and disadvantages, and there have been few reports directly comparing the outcomes of these techniques. This report compares the clinical outcomes of BET vs BTT performed by a single operator and discusses some technical considerations derived from this study and the literature. METHODS: The demographic and outcome data of patients who underwent second-stage basilic vein transposition at an ambulatory surgery center from February 2009 to January 2016 were collected and analyzed. RESULTS: Of the 99 patients identified, 53% were male and 64% were diabetic; the mean age was 61 ± 16 years; 27 had BTT and 72 had BET; the mean follow-up was 26.2 ± 20.5 (range, 1-83) months. The primary patency, assisted primary patency, and secondary patency rates of the whole fistula conduit were 26%, 91%, and 100% for the BTT group and 46%, 98%, 100% for the BET group at 1 year and 21%, 80%, 94% for the BTT group and 38%, 98%, 98% for the BET group at 2 years. The primary patency rate of the basilic vein (segment of the fistula conduit superficialized by transposition) at 1 year was significantly lower for the BTT group vs the BET group (26% vs 61%; P = .004). The average number of percutaneous interventions required for the basilic vein was significantly more for the BTT group vs the BET group (1.5 ± 1.3 vs 0.6 ± 1.0/access-year; P = .007). Based on a Cox regression analysis, the surgical techniques were the only clinical factor that significantly affected the basilic vein primary patency (hazard ratio of 2.28 in favor of BET over BTT; 95% confidence interval, 1.25-4.14; P = .007). CONCLUSIONS: BET is a reliable approach that yields a high cumulative fistula survival rate. Compared with BTT, BET is associated with improved basilic vein primary patency and reduced need for endovascular interventions.