Outcomes of femoral artery ligation for treatment of infected femoral pseudoaneurysms due to drug injection.

OBJECTIVE: Infected femoral artery pseudoaneurysms (IFAPs) are a known complication of illicit intravenous drug injection. As the opioid crisis in our country continues to worsen, we will likely see more IFAPs and algorithms for management of these patients will need to be elucidated. The aim of this study was to describe the surgical management and outcomes of patients presenting with IFAPs treated with femoral artery ligation. METHODS: This is a single-center, retrospective study of consecutive patients presenting to our institution with IFAPs associated with illicit drug injection between 2004 and 2017 and treated with primary ligation. Primary end points included major adverse limb events (MALE) and death. Baseline demographics, clinical features, and long-term outcomes were recorded. RESULTS: Over the study period, 60 IFAPs were managed with arterial ligation in 58 patients. Fifty-two percent of patients underwent common femoral artery ligation, 30% of patients underwent a triple ligation (ligation of the common femoral artery, profunda femoris artery, and superficial femoral artery), and 18% of patients underwent ligation of the superficial femoral artery only. The average postoperative ankle-brachial index was 0.47. None of the patients underwent revascularization at the index procedure. In our early experience, four patients (6.6%) underwent delayed revascularization with a prosthetic bypass. Two of the patients subsequently re-presented with infected bypass grafts and required the only major amputations in our series. The mean follow-up was 51.3 months and four patients were lost to follow-up. No differences were identified in MALE between patients undergoing a femoral artery ligation vs a triple ligation. Nine patients (15%) died during the follow-up period and all deaths were unrelated to IFAP treatment; the mean survival from procedure to death was 28 months. CONCLUSIONS: We describe the largest series in the United States of IFAP related to illicit drug use treated with femoral artery ligation and found it is a safe procedure associated with low MALE. Reconstruction is not recommended and is associated with graft infection. Although the mortality rate in these patients was high, it was not related to the ligation procedure.

Management of Moderate Blunt Thoracic Aortic Injuries in Patients with Intracranial Hemorrhage.

BACKGROUND: Blunt thoracic aortic injuries (BTAIs) are the second most common cause of death due to blunt-force trauma in the United States. Patients with minimal injuries do not typically require surgical repair, whereas patients with severe injuries are treated emergently. Moderate aortic injuries are repaired in a semielective fashion, but the optimal management of patients with moderate BTAI with associated intracranial hemorrhage (ICH) is unknown. We sought to analyze the management and outcomes of patients presenting with concomitant moderate BTAI and ICH. METHODS: Consecutive patients who received a thoracic endovascular aortic repair (TEVAR) at our institution for treatment of moderate BTAI between January 2014 and December 2017 were retrospectively reviewed as part of an institutional review board-approved protocol. Patients were classified by our BTAI classification into "minimal", "moderate", or "severe". ICH was identified on computed tomography scan and its severity determined by the neurosurgical team. Outcome measures included surgical timing and surgical outcomes. RESULTS: Fifty-two patients had a moderate BTAI and underwent TEVAR, 20 (38 %) of whom presented with ICH. Median time from admission to surgery was 58.5 hr for patients with ICH and 26.5 hr for non-ICH patients. Intraoperative heparin was administered in all patients without ICH and in 19 of 20 (95%) patients with ICH after the ICH met criteria for stability. Protamine reversal was utilized in 80% of patients with ICH and 75% of non-ICH patients. No patient developed ischemic stroke or spinal cord ischemia. Worsening ICH was seen in only one patient, who also received heparin infusion for pulmonary embolus 24 hr before TEVAR. There were no aortic-related mortalities in either group. Thirty-day all-cause mortality was 5% for patients with ICH and 3% for non-ICH patients. CONCLUSIONS: Patients with moderate BTAI and stable ICH are not at increased risk of TEVAR-related complications. Administration of intraoperative heparin during TEVAR appears to be safe and does not worsen ICH.

Limb Salvage Does Not Predict Functional Limb Outcome after Revascularization for Traumatic Acute Limb Ischemia.

BACKGROUND: Traumatic vascular injury leading to acute limb ischemia (ALI) is an uncommon problem with a potential for high morbidity. We describe a contemporary series of patients with traumatic ALI managed primarily by vascular surgeons at a tertiary referral center and review factors associated with limb salvage and functional limb outcomes. METHODS: We conducted a single institution, retrospective review of all patients requiring revascularization for upper extremity (UE) and lower extremity (LE) ALI secondary to trauma from 2013 to 2016. Demographic data, transfer timing, injury severity score (ISS), Rutherford classification (RC), preoperative imaging, level of occlusion, procedural information, fasciotomy characteristics, and discharge disposition were reviewed. Outcome measures included limb salvage and functional limb outcomes. RESULTS: We identified 68 patients with traumatic ALI requiring revascularization. The majority of patients had moderate ISS scores, were RC 2a or 2b on presentation (65%), were transferred from another institution (53%), and underwent preoperative imaging (62%) with expeditious time to operation (median 4.5 hr). The most common location of vascular injury for UE was axillary-brachial (88%) and for LE was femoral-popliteal (69%). Open vascular procedures dominated the treatment strategy, and the median number of operations was 3. Fasciotomy was performed in 25% of UE and 58% of LE injuries. Shunts were utilized in only 2 patients. Overall LS was 94% for UE and 78% for LE. The median length of stay (LOS) was 11 days, with 25% of patients discharged to a skilled nursing facility. Follow-up was obtained for 59% of patients. For UE injuries, 57% of patients had no or minimal functional deficits, while 33% had major functional deficits and 10% underwent amputation. For LE injuries, 68% of patients had no or minimal functional deficits, while 6% had major functional deficits, and 26% had undergone amputation. Rutherford class and the number of operations performed were independent predictors of amputation and functional limb at follow-up in our logistic regression model (P < 0.05). CONCLUSIONS: Revascularization for traumatic ALI yields high limb salvage rates in patients with RC 1 and 2 ischemia and patients with UE injuries. However, limb salvage does not necessarily equate to good functional outcomes. This signifies the complex nature of injuries in this patient population, especially when multiple operations are required.

Implementation and results of a practical grading system for blunt thoracic aortic injury.

OBJECTIVE: We previously proposed a grading system for blunt thoracic aortic injury (BTAI) designed to guide therapy. This study analyzed our outcomes since implementing this system. METHODS: A single-center, retrospective study was conducted of consecutive patients presenting with BTAI between January 2014 and December 2017. This grading system classified injuries into minimal, moderate, or severe on the basis of computed tomography imaging. Primary end points included timing of operation and mortality. Secondary end points included associated injuries, aortic anatomy, and operative details as well as 30-day follow-up. RESULTS: During the study period, 87 patients with BTAI were identified. The majority of patients had a moderate injury occurring just distal to the left subclavian artery (LSA); 59 patients underwent thoracic endovascular aortic repair (TEVAR), whereas none of the patients with minimal injury (n = 24) required surgical treatment. The mean time to repair was 53 hours (1-191 hours) for moderate injury and 3.6 hours (0-7 hours) for severe injury. The average diameter and length of the endograft was 26 mm and 112 cm, respectively, and the LSA was covered in 42% of patients. Intravascular ultrasound to confirm sizing was used in 83% of cases. Most patients (92%) received intravenous heparin during TEVAR; the remainder received only heparin sheath flush because of concern for intracranial hemorrhage. None of the patients underwent LSA revascularization or developed stroke or spinal cord ischemia as a result of the procedure. Operative complications were seen in 6% of patients and included 1 femoral pseudoaneurysm, 1 lower extremity compartment syndrome, 1 type II endoleak requiring LSA embolization, and 1 intracranial bleed. The 30-day mortality was 7% (one aorta-related death). On 30-day postoperative follow-up, computed tomography imaging uniformly revealed positive aortic remodeling, and no secondary aortic intervention was required. CONCLUSIONS: Institutional implementation of our grading system has streamlined treatment of BTAI, and our results confirm the following: patients with minimal injury do not require surgical treatment; patients with moderate injury can safely undergo TEVAR in a semielective manner once they are stable from other injuries; and patients with severe injury require emergent repair. These procedures are expeditious and can be successfully performed percutaneously with a single endograft. Complications are rare, and follow-up reveals excellent remodeling of the aorta, likely resulting in lengthened interval surveillance requirements for these patients.

Aortic neck dilation is not associated with adverse outcomes after fenestrated endovascular aneurysm repair.

OBJECTIVE: Long-term outcomes after endovascular aneurysm repair (EVAR) are threatened by aortic neck dilation (AND), graft migration, and subsequent endoleak development. The aim of this study was to determine the rate of AND and the occurrence of endoleaks after fenestrated EVAR of juxtarenal aneurysms with physician-modified endovascular grafts (PMEGs). METHODS: The study included 77 patients presenting with asymptomatic and ruptured juxtarenal abdominal aortic aneurysms treated with PMEGs who received radiologic follow-up. Analysis of computed tomography images took place on a three-dimensional workstation (TeraRecon, San Mateo, Calif). Aortic neck diameter was measured before and after EVAR at the lowest patent renal artery outer wall to outer wall. Significant AND was defined as >3-mm increase between baseline and follow-up, and sac regression >5 mm was considered significant. The patient's 1-month initial postoperative computed tomography measurement was considered baseline. The rate of AND was measured by comparing the baseline measurement with measurements at 6 months, 12 months, and annually thereafter up to 4 years. RESULTS: In this cohort of patients, 75% were men with a mean age of 74 ± 7.9 years. Median preoperative aneurysm size was 62 (57-73) mm, and median follow-up was 12 (3.5-30) months. Mean endograft oversizing was 17% ± 12.5%, and mean seal zone length was 41 ± 11 mm. At 1-year follow-up, the median aortic neck increase was 1.7 (0-3) mm. Maximum aneurysm size decreased dramatically during the first postoperative year, with significant sac regression in 65% of the patients. Aortic neck diameter at 1 year did correlate positively with the percentage of device oversizing. No other correlations were found. During the 4-year follow-up, there were no cases of type IA endoleaks. CONCLUSIONS: AND does not influence outcome after endovascular repair of juxtarenal aneurysms using PMEGs. These midterm results support the applicability of PMEGs in juxtarenal aneurysm repair.

Preoperative risk score for the prediction of mortality after repair of ruptured abdominal aortic aneurysms.

OBJECTIVE: Even in the ruptured endovascular aneurysm repair first era, there are still patients who will not survive their ruptured abdominal aortic aneurysm (rAAA). All previously published mortality risk scores include intraoperative variables and are not helpful with the decision to operate or in providing preoperative patient and family counseling. The purpose of this study was to develop a practical preoperative risk score to predict mortality after repair of rAAA. METHODS: Data of all patients with rAAA presenting between January 1, 2002, and October 31, 2013, were collected. Logistic regression was used to evaluate predictive variables both univariately and jointly, and the results of multivariate models guided the definition of the final simplified scoring algorithm. RESULTS: There were 303 patients who presented during the study period. Sixteen patients died in the emergency department, en route to surgery, or after choosing comfort care. Preoperative variables most predictive of mortality were age >76 years (odds ratio [OR], 2.11; confidence interval [CI], 1.47-4.97; P = .011), creatinine concentration >2.0 mg/dL (OR, 3.66; CI, 1.85-7.24; P < .001), pH <7.2 (OR, 2.58; CI, 1.27-5.24; P = .009), and systolic blood pressure ever <70 mm Hg (OR, 2.70; CI, 1.46-4.97; P = .002). Assigning 1 point for each variable, patients were stratified according to the preoperative rAAA mortality risk score (range, 0-4). For all repairs, at 30 days, patients with 1 point suffered 22% mortality; 2 points, 69% mortality; and 3 points, 80% mortality. All patients with 4 points died. There was a mortality benefit for ruptured endovascular aneurysm repair across all categories. CONCLUSIONS: Our rAAA mortality risk score is based on four variables readily assessed in the emergency department and allows accurate prediction of 30-day mortality after repair of rAAAs. It also has a direct impact on clinical decision-making by adding prognostic information to the decision to transfer patients to tertiary care centers and aiding in preoperative discussions with patients and their families.

The Use of Smart Phone Thermal Imaging for Assessment of Peripheral Perfusion in Vascular Patients.

BACKGROUND: Ankle-brachial index (ABI) is a reliable method to evaluate extremity perfusion but can be prohibitive to obtain secondary to patient discomfort or extremity trauma. This study investigates smart phone-based forward looking infrared imaging to assess peripheral perfusion using thermal ABI (tABI). METHODS: ABIs were measured by a certified vascular laboratory. Thermographs of each extremity (hands/feet) were obtained, and maximum surface temperature was recorded. tABI was calculated by dividing the lower extremity (LE) temperature by the upper extremity (UE). ABI and tABI were compared using Pearson's correlation and Bland-Altman plot. RESULTS: Twenty-three patients (45 limbs) had ABI's and thermographs recorded on the same day. Median ABI was 0.89 (range 0.33-1.46, IQR 0.4). Median LE temperature was 83.0°F (range 60.7-96.9°F, IQR 14.1). Median UE temperature was 91.2°F (range 81.9-94.6°F, IQR 3.4). Median tABI was 0.93 (range 0.33-1.4, IQR 0.2). Positive correlation was seen between ABI and tABI with Pearson analysis (r = 0.83, P < 0.0001) and Bland-Altman plot (bias -0.01, LOA -0.13 to -0.12). CONCLUSIONS: Thermal imaging correlates with ABI in the evaluation of extremity perfusion. Smart phone-based FLIR can be used to determine peripheral perfusion in clinical settings where ABI is difficult to obtain.

Gender Difference in Offspring's Alcohol Use Disorder by 21 Years: A Longitudinal Study of Maternal Influences.

AIMS: There is little known about the extent to which maternal alcohol consumption influences offspring's alcohol use disorder. This study aims to examine whether different maternal alcohol consumption trajectories predict gender difference in adolescent alcohol use disorder at child age 21 years. METHODS: Data are from a prospective cohort, the Mater-University of Queensland Study of Pregnancy (MUSP) and its outcomes. The study involves 2531 mother-child pairs for whom data are available at the 21-year follow-up survey. Maternal alcohol consumption trajectories were determined by group-based trajectory modelling. Offspring's lifetime ever alcohol use disorder was assessed using DSM-IV diagnostic criteria. RESULTS: Over 14 years of follow-up after the birth of a child, three distinct alcohol consumption trajectories were identified (abstainer, low-stable. and moderate-escalating drinker). A maternal trajectory of moderate-escalating alcohol consumption independently predicted offspring's lifetime ever alcohol use disorder at 21 years after adjustment for a range of potential confounders. "Cross-gender influence" is observed in the study. CONCLUSIONS: A maternal life course pattern of alcohol consumption may have an independent effect on offspring alcohol consumption, with male offspring being more vulnerable to the effects of maternal alcohol use than are female offspring. Programs intended to address alcohol consumption by adolescents and young adults need to focus on the behaviors of both parents but acknowledging that maternal patterns of alcohol consumption may be particularly important for male offspring.

Temporal patterns and predictors of bullying roles among adolescents in Vietnam: a school-based cohort study.

Although many cross-sectional studies have examined bullying experiences and correlated factors among adolescents in schools, relatively little is known about the extent to which bullying roles are stable or fluid over time. This short-term quantitative longitudinal study in Vietnam examined temporal patterns and predictors of bullying roles over an academic year. A total of 1424 middle and high school students aged 12-17 years completed two anonymous, self-administered questionnaires six months apart in 2014 and 2015. Young people were classified into different bullying roles as follow: not-involved (38.9%), victims only (24%), bullies only (6.6%), and bully-victims (40.4%) across the two times. About 60% of all surveyed students experienced bullying either as victim, bully, or bully-victim during the year. Of these students, nearly three in four indicated unstable bullying roles over time. Multivariate multinomial logistic regressions indicated factors ranging from individual (age, gender, and mental health) to family (social support, parental supervision and monitoring, witnessing parental violence, and conflict with siblings), school (perceived social support, teachers' attempt to stop bullying at school), and peers (social support, students' attempt to stop bullying at school) have significant associations with levels of bullying involvement. Implications for bullying prevention programs nationally and internationally are discussed.

Intravascular ultrasound is a critical tool for accurate endograft sizing in the management of blunt thoracic aortic injury.

BACKGROUND: Accurate measurement of true aortic luminal diameter (ALD) is critical for endograft sizing in endovascular treatment of blunt thoracic aortic injury (BTAI), but ALD is dynamic and changes with respect to patients' hemodynamic status. This study aimed to characterize how ALD at the time of diagnosis of BTAI compares with ALD at the time of endovascular repair and later at follow-up. METHODS: This is an Institutional Review Board-approved, single-institution retrospective analysis of prospectively obtained data. Patients were included who presented between July 2007 and December 2012 with computed tomography angiography (CTA)-diagnosed BTAI; who underwent thoracic endovascular aortic repair (TEVAR); and who underwent preoperative CTA, intraoperative intravascular ultrasound (IVUS), and postimplantation CTA. Comparison measurements of the ALD were made among CTA and IVUS images at the level of the left subclavian artery (LSCA) and between initial CTA and postimplantation CTA at 10, 15, and 20 cm distal to the LSCA. Theoretical endograft sizes were determined and compared for each ALD at the LSCA. RESULTS: Twenty-two patients were included in the analysis. Mean age was 38 ± 14 years (range, 17-61 years), with 82% men and mean Injury Severity Score of 43 ± 11 (range, 24-66). Mean time from emergency department admission to initial CTA was -1.2 ± 5 hours (range, -13 to 11.5 hours; negative time implies imaging at an outside facility before admission). Mean time from initial CTA to IVUS was 1.2 ± 1.4 days (range, 2.5 hours-5.7 days) and from IVUS to postimplantation CTA 33 ± 45 days (range, 17 hours-169 days). Overall, ALD measured by IVUS was significantly larger than that by initial CTA (Δ2.5 ± 3.1 mm; P < .05). ALD was also larger at 10, 15, and 20 cm distal to the LSCA in comparing the postimplantation CTA with the initial CTA (Δ2.4, 2.0, and 2.0 mm, respectively; all P < .05). More than half the devices would be sized differently with ALD measured by IVUS at the time of TEVAR vs initial CTA. CONCLUSIONS: The ALD of patients with BTAI is significantly larger when it is measured by IVUS at the time of TEVAR compared with at the time of initial CTA. This difference in ALD may translate to undersizing of endografts used in TEVAR for BTAI. IVUS at the time of TEVAR provides a more accurate measurement of the actual ALD and should be used for endograft sizing for patients with BTAI.

Outcomes after stent graft therapy for dissection-related aneurysmal degeneration in the descending thoracic aorta.

OBJECTIVE: Stent graft therapy has emerged as an alternative to open surgery in the management of chronic dissection-related aneurysmal degeneration (DRAD) in the descending thoracic aorta (DTA). The incidence of perioperative complications, need for secondary aortic intervention (SAI), and rate of aneurysmal false-lumen thrombosis have not been thoroughly described. METHODS: Perioperative and midterm outcomes in patients who underwent stent graft therapy for chronic DRAD DTA at a single institution between January 2006 and September 2013 were retrospectively analyzed. Preoperative anatomic factors, including the number of visceral and renal side branches off the false lumen, and false lumen volume, were analyzed for their ability to predict treatment failure. Treatment failure was defined as death, need for a SAI, and failure to achieve thrombosis of the DRAD DTA. Treatment success was defined as thrombosis of the false lumen in the area of the DRAD DTA with stability or a decrease in the maximum diameter of the DRAD DTA. RESULTS: During the study period, 47 patients underwent stent graft therapy for chronic DRAD DTA. Patients were a mean age of 58.3 ± 11.7 years, 74.5% (n = 35) were male, and 14.9% (n = 7) had a history of connective tissue disease. The left subclavian artery was covered in 48.9% (n = 23), and revascularization was performed in 87.0% (n = 20). Spinal drains were used in 74.5% (n = 35). Spinal cord ischemia developed in 6.4% (n = 3), which resolved in two and improved in one. No retrograde aortic dissections occurred. The 30-day mortality was 4.3% (n = 2); one death was in a patient with rupture. Mean clinical follow-up was 35.1 ± 20.9 months. The 5-year Kaplan-Meier survival was 89% ± 5%. Treatment failure occurred in 18 patients (38.3%): 9 required SAIs, 6 did not have thrombosis of the false lumen in the area of the DRAD DTA, and 4 died, with 1 patient dying during a SAI. No preoperative anatomic factor predicted treatment failure. The 5-year freedom from treatment failure was 54% ± 9%. Including the nine patients who underwent SAI, treatment success was achieved in 85.2% of patients. CONCLUSIONS: In this single-center experience of stent graft therapy for chronic DRAD DTA, treatment success was achieved in 85% of patients after a SAI rate of 20%. No preoperative anatomic factor predicted treatment failure, which occurred in almost 40% of the patients. Identifying predictors of treatment failure may improve future outcomes.

Predictors of maternal drinking trajectories before and after pregnancy: evidence from a longitudinal study.

BACKGROUND: Little is known about patterns of change in alcohol consumption and predictors of these patterns over the prenatal to postnatal period. AIMS: To determine trajectories of maternal alcohol consumption before and after pregnancy and predictors of these trajectories. MATERIALS AND METHODS: A total of 6597 Australian women were sampled from a longitudinal study. Group-based trajectory modelling was applied to determine drinking trajectories from prepregnancy, early pregnancy, late pregnancy and 6 months after the birth. Predictors associated with drinking trajectories were examined using multinomial logistic regression. RESULTS: Three trajectories of maternal alcohol consumption were identified: abstainers/minimal consumption (53.2%), light consumption (39.4%) and heavy consumption (7.4%). The heavy consumption group substantially reduced their consumption in pregnancy but increased their consumption once the baby was born. Some 80.0% of this group were breastfeeding their babies. The light consumption group had only minor changes in their drinking pattern. Lower family income, being married, high frequency of church attendance, low level of adversity, poor health lifestyle, remaining married to original partner and having many children predicted membership of the abstaining/minimal consumption trajectory. Being unmarried, having only one child, having unhealthy health lifestyle and never going to church predicted membership of the heavy consumption group. CONCLUSION: Women who consume higher levels of alcohol prior to their pregnancy reduce their consumption once pregnant, but tend to increase their alcohol consumption shortly after the birth. A public health campaign dealing with predictors associated with heavier alcohol consumption and safe breastfeeding targetted at these women is needed.

Favorable discharge disposition and survival after successful endovascular repair of ruptured abdominal aortic aneurysm.

OBJECTIVE: Endovascular repair of ruptured abdominal aortic aneurysm (rEVAR) has been shown to improve perioperative outcomes compared with open surgical repair (OSR). Follow-up of these patients, however, is lacking. In this study, we compare the discharge disposition and midterm survival of ruptured aneurysm patients who survived treatment with either rEVAR or OSR. METHODS: We performed an institutional review board-approved, single-institution, retrospective review of all patients with ruptured abdominal aortic aneurysms (rAAAs) admitted from July 2007 to February 2012. Primary outcomes were discharge disposition and midterm survival (>30 days after the index operation). We also evaluated compliance with follow-up and prevalence of endoleak. RESULTS: A total of 118 patients were analyzed. Eight patients received only comfort care, 10 died in the operating room, 39 underwent OSR, and 61 had rEVAR. Average age and sex were similar (OSR, 77 ± 7.8 years, 85% male; rEVAR, 74 ± 7.4 years, 79% male). Seventy-two survived to discharge (54% OSR [21/39]; 84% rEVAR [51/61]; P = .001). OSR patients had longer lengths of intensive care unit and total length of stay than rEVAR (11.8 ± 10.4/23 ± 16.4 days vs 6.3 ± 8.5/12.3 ± 13.0 days; P = .002/.02). Only 19% (4/21) of patients were discharged home after OSR, rather than to a skilled nursing facility. Significantly more rEVAR patients were discharged to home rather than a skilled nursing facility (65%; 33/51) (P = .0004). Overall, the follow-up rate for determination of survival for patients who lived past 30 days was 86% (56/65; median, 14 months; 25th-75th interquartile, 3.1-27.8). Multivariable logistic regression revealed only the type of procedure performed and perioperative hypotension predicted discharge destination. Kaplan-Meier analysis revealed a significant midterm survival benefit for patients after rEVAR compared with OSR (P = .01, log-rank). Subgroup analysis of survivors past 30 days revealed similar rates of midterm survival (P = .7, log-rank). Overall, midterm relative risk reduction for death after rEVAR vs OSR was 35% (95% confidence interval, 0.06-0.59). CONCLUSIONS: We have previously demonstrated that successful utilization of rEVAR improves the early survival of rAAA patients compared with OSR. This study shows that more patients are able to be discharged to home after rEVAR and that the early survival advantage is continued in midterm follow-up, suggesting that rEVAR should be attempted first when feasible. Further studies are needed to determine the long-term durability of endovascular repair in the management of rAAA as well as the impact on cost and long-term quality of life.

A new classification scheme for treating blunt aortic injury.

BACKGROUND: There are numerous questions about the treatment of blunt aortic injury (BAI), including the management of small intimal tears, what injury characteristics are predictive of death from rupture, and which patients actually need intervention. We used our experience in treating BAI during the past decade to create a classification scheme based on radiographic and clinical data and to provide clear treatment guidelines. METHODS: The records of patients admitted with BAI from 1999 to 2008 were retrospectively reviewed. Patients with a radiographically or operatively confirmed diagnosis (echocardiogram, computed tomography, or angiography) of BAI were included. We created a classification system based on the presence or absence of an aortic external contour abnormality, defined as an alteration in the symmetric, round shape of the aorta: (1) intimal tear (IT)-absence of aortic external contour abnormality and intimal defect and/or thrombus of <10 mm in length or width; (2) large intimal flap (LIF)-absence of aortic external contour abnormality and intimal defect and/or thrombus of ≥10 mm in length or width; (3) pseudoaneurysm-presence of aortic external contour abnormality and contained rupture; (4) rupture-presence of aortic external contour abnormality and free contrast extravasation or hemothorax at thoracotomy. RESULTS: We identified 140 patients with BAI. Most injuries were pseudoaneurysm (71%) at the isthmus (70%), 16.4% had an IT, 5.7% had a LIF, and 6.4% had a rupture. Survival rates by classification were IT, 87%; LIF, 100%; pseudoaneurysm, 76%; and rupture, 11% (one patient). Of the ITs, LIFs, and pseudoaneurysms treated nonoperatively, none worsened, and 65% completely healed. No patient with an IT or LIF died. Most patients with ruptures lost vital signs before presentation or in the emergency department and did not survive. Hypotension before or at hospital presentation and size of the periaortic hematoma at the level of the aortic arch predicted likelihood of death from BAI. CONCLUSIONS: As a result of this new classification scheme, no patient without an external aortic contour abnormality died of their BAI. ITs can be managed nonoperatively. BAI patients with rupture will die, and resources could be prioritized elsewhere. Those with LIFs do well, and currently, most at our institution are treated with a stent graft. If a pseudoaneurysm is going to rupture, it does so early. Hematoma at the arch on computed tomography scan and hypotension before or at arrival help to predict which pseudoaneurysms need urgent repair.

Blunt abdominal aortic injury.

BACKGROUND: Blunt abdominal aortic injury (BAAI) is a rare injury with less than 200 cases in the current reported world literature, mostly in case report format. We sought to describe the experience of a high-volume trauma center and to provide a contemporary review of the literature to better understand the natural history and management of this injury. METHODS: This was a retrospective review of patients with BAAI between 1996 and 2010. Data collected included demographics, mechanism of injury, associated injuries, type of intervention, subsequent imaging, and follow-up. BAAI was classified by the presence of external aortic contour abnormality noted as an intimal tear, large intimal flap, pseudoaneurysm, or free rupture. Abdominal aorta zones of injury were classified by possible surgical approaches as zone I (diaphragmatic hiatus to superior mesenteric artery [SMA]), zone II (includes SMA and renal arteries), and zone III (from the inferior aspect of the renal arteries to the aortic bifurcation). RESULTS: We identified 28 individuals (68% male) with BAAI (median age, 28.5; range, 6-61 years). The median injury severity score was 45 (range, 16-75), and 39% were hypotensive at presentation. BAAI presented as intimal tear (21%), large intimal flap (39%), pseudoaneurysm (11%), and free rupture (29%). Zone III was the most common location of injury. Management depended on the location and type of injury: nonoperative (32%), open aortic repair (36%), endovascular repair (21%), and multimodality (10%). Overall mortality was 32%. Most deaths occurred during the initial operative exploration. The mortality rate of free aortic rupture was 100%. Intimal tears resolved or remained stable. Median follow-up was 15.5 months (range, 8 days-7.5 years). Vascular complications due to repair included a thrombosed access femoral artery during an endovascular repair and death of a patient who underwent a hybrid repair. CONCLUSIONS: This is the largest BAAI series described in the English literature at one institution. BAAIs range from intimal tears to free rupture, with outcomes and management correlating with type and location of injury. Nonoperative management with blood pressure control using ß-blockers coupled with antiplatelet therapy and close follow-up is successful in individuals with intimal tears with minimal thrombus formation because they remain stable or resolve on follow-up. Free rupture remains a devastating injury, with 100% mortality. For all other categories of aortic injury, successful repair correlates with a favorable prognosis.

Thoracic aorta to popliteal artery bypass for bilateral lower-extremity critical limb ischemia.

Thoracic aortic to infrainguinal arterial bypasses are rare in the literature, even more so when the outflow is the popliteal artery bilaterally. The case of a patient presenting with critical limb ischemia, chronic infrarenal aortic occlusion, and recurrent thrombosis of a unilateral axillobifemoral graft managed with thoracoretroperitoneal bitransobturator bipopliteal bypass is presented. The patient's vascular history was significant for multiple previous groin procedures for thrombectomy of her axillobifemoral graft, aortomesenteric bypass, redo aortomesenteric bypass for graft thrombosis, and multiple bowel resection procedures for acute mesenteric ischemia. The thoracic aorta and popliteal arteries were selected as sites for proximal and distal anastomoses, respectively, given anticipated difficulty in exposing the supraceliac aorta and femoral arteries. The technique of this operative approach is discussed.

Endovascular treatment of axillosubclavian arterial transection in patients with blunt traumatic injury.

Axillosubclavian arterial transection due to blunt traumatic injury poses a treatment challenge in the multiply injured patient. Endovascular repair can be technically successful if the injury is focal. We describe an endovascular technique utilizing combined brachial and femoral access to create a through-and-through brachial-femoral wire and repair the arterial injury with a covered stent.

Repair of blunt thoracic outlet arterial injuries: an evolution from open to endovascular approach.

BACKGROUND: Thoracic outlet artery injuries due to blunt trauma are uncommon. Exposure of these arteries is associated with significant morbidity and mortality. An endovascular approach is a less invasive alternative approach for these technically challenging injuries. METHODS: A retrospective review of patients who presented with blunt traumatic injuries to the innominate, subclavian, and axillary arteries between 1998 and 2009 was performed. Demographic data, concomitant injuries, preoperative workup, treatment, and outcomes were recorded. RESULTS: During the study period, 34 patients (80% men) meeting selection criteria were admitted (11 innominate, 16 subclavian, and 7 axillary). Management was nonoperative in 6, open in 16, and endovascular in 12 patients. In the latter group, eight patients had successful stent-graft insertions. These were approached in an antegrade femoral or retrograde brachial fashion. In three cases of complete artery transaction, both methods were used. Shorter operative time (149 minutes vs. 230 minutes; p = 0.03) and less blood loss (50 mL vs. 1,225 mL; p = 0.03) were seen in the endovascular group compared with the open repair group. There was a trend for less blood transfusion, but it was not significant (0 median units vs. 4.5 median units; p = 0.3). Hospital length of stay was shorter (19 days vs. 29 days; p = 0.4). CONCLUSIONS: Covered stents are a feasible alternative to open repair in the multiply injured blunt trauma patients with thoracic outlet arterial injuries. This can be used in the damage control setting as it offers shorter operative time, less blood loss, and overall less morbidity to the patient. Long-term follow-up is needed.

Management of ruptured abdominal aortic aneurysm in the endovascular era.

OBJECTIVES: Our institution treats about 30 patients per year with ruptured abdominal aortic aneurysms (rAAA). Between 2002 and 2007, our 30-day mortality averaged 58%. In July 2007, we implemented an algorithm to promote endovascular aneurysm repair (EVAR) when feasible. This report describes the outcome with this approach. METHODS: Data on patients presenting with rAAA between July 1, 2002, and June 30, 2007, were reviewed and used for comparison to prospectively collected data. Data on patients presenting between July 1, 2007, and April 30, 2009, were collected on all patients after implementation of a structured protocol. The primary outcome measure was 30-day mortality. Data were analyzed using logistic regression. Kaplan-Meier survival curves and a log-rank test were performed to compare survival times for three groups (pre-protocol, post-protocol with open surgery, and post-protocol with EVAR). RESULTS: During the study period, 187 patients with rAAA presented to our institution. Before implementation of the algorithm, 131 patients with rAAA presented and 128 were treated. The 30-day mortality rate was 57.8%. After implementation of the protocol, 56 patients with rAAA were managed. Twenty-seven patients (48%) underwent successful EVAR, and 24 patients (43%) underwent open repair. Five patients (9%) underwent comfort care only. In the post-protocol period, 5 patients in the EVAR group (18.5%) and 13 patients in the open group (54.2%) died during the follow-up period for an overall 30-day mortality rate of 35.3% (P = .008 vs 57.8% pre-protocol). After implementation of a structured protocol for managing rAAA, there was a relative risk reduction in 30-day mortality of 35% compared to the time before implementation of the protocol (95% confidence interval [CI], 14%-51%) corresponding to an absolute risk reduction of 22.5% (95% CI, 6.8%-38.2%) and an odds ratio of 0.40 (95% CI, 0.20-0.78; P = .007). After adjusting for key factors predicting mortality, the odds ratio is 0.25 (95% CI, 0.10-0.57; P = .001). CONCLUSION: Use of an algorithm favoring endovascular repair resulted in a highly significant reduction in rAAA mortality in our urban hospital. Thirty-day mortality for open repair was no different between pre- and post-protocol eras. With modern techniques of resuscitation and surgical management, a majority of patients presenting with rAAA can survive.

Hypothermia is associated with increased mortality in patients undergoing repair of ruptured abdominal aortic aneurysm.

PURPOSE: To evaluate the impact of hypothermia on mortality in patients presenting with ruptured abdominal aortic aneurysms (rAAA). METHODS: Between July 2007 and September 2009, 73 patients with ruptured AAAs presented to our Emergency Department (ED). Thirteen patients did not receive surgical treatment; of the 60 patients (46 men; mean age 76 years, range 63-90) who did, 35 had endovascular aneurysm repair (EVAR) and 25 open repair. Body temperatures, which were recorded upon arrival to the ED and operating room, during the procedure, and just prior to leaving the operating room, were analyzed for any association with mortality or hypotension. The primary outcome measure was the 30-day mortality rate. RESULTS: Six (17%) patients in the EVAR group and 10 (40%) patients in the open group died during the 30-day period. Temperature upon arrival to OR, lowest temperature recorded during the procedure, and temperature at the end of the procedure were higher among survivors (p<0.005), independent of the repair technique implemented. Patients in the EVAR group left the OR with a mean temperature of 35.5 degrees C versus 35.0 degrees C for patients in the open group (p = 0.12). CONCLUSION: Hypothermia is associated with increased mortality after repair of rAAA. Efforts to correct hypothermia are more frequently successful in patients undergoing EVAR. Increased communication with anesthesia providers, as well as aggressive measures to correct hypothermia, including active intravascular rewarming methods, should be considered to improve mortality in this gravely ill patient population.