Treatment strategy for traumatic innominate arterial injury.

PURPOSE: To discuss and share the experience of treatment of traumatic innominate arterial injury. METHODS: A retrospective analysis was performed on patients with innominate arterial injuries admitted from January 2016 to July 2018 at the department of vascular surgery, Beijing Jishuitan Hospital, China. All the arterial injuries were confirmed by arteriography. Clinical data including mechanism of injury, type of injury, demographics, concomitant injuries, time interval from trauma to blood flow reconstruction, and operation methods were collected. Follow-up program included outpatient visit and duplex-ultrasonography. SPSS version 23.0 was adopted for data analysis. Categorical variables are presented as number and/or frequency and continuous variables as mean ± standard deviation. RESULT: Altogether 7 patients were included and 6 (85.7%) were male. The mean age of patients was (29.43 ± 7.98) years, range 19-43 years. Six patients had isolated innominate arterial injuries and the rest 1 combined innominate arterial and vein injuries. The injury causes were road accidents in 3 patients, stab wound in 2, gunshot wound in 1, and crush injury in 1. All the 7 patients presented hemorrhagic shock at admission, which was timely and effectively corrected. No perioperative death or technical complications occurred. Intimal injury (n = 2) and partial transaction (n = 2) of the innominate artery were treated with covered stents. Two patients with complete transection of artery received vascular reconstruction by artificial grafts. One patient with partial transaction received balloon dilation and open surgical repair (hybrid operation). The mean time interval from trauma to blood flow reconstruction was (4.27 ± 0.18) h, range 4.0-4.5 h; while the operation time was (48.57 ± 19.94) min, range 25-75 min. Cerebral infarction occurred in one patient with brain injury due to anticoagulation contraindication. The average follow-up was (13.29 ± 5.65) months, range 6-24 months. No severe stenosis, occlusion, and thrombosis of covered stents or artificial vessels were found by color Doppler ultrasound. CONCLUSION: Urgent control of hemorrhage and restoration of blood supply are critical for the treatment of traumatic innominate arterial injury. Endovascular therapy is a feasible and effective method with short operation time and less trauma.

Comparison of traditional vascular reconstruction with covered stent in the treatment of subclavian artery injury.

PURPOSE: To explore the significance of traditional vascular reconstruction and covered stent for limb salvage after subclavian artery injury. METHODS: Patients with subclavian artery injury admitted to Beijing Jishuitan Hospital from January 2010 to December 2018 were retrospectively analyzed. All the injuries have been confirmed by intraoperative exploration, computed tomography angiography or digital subtraction angiography. Complete or partial amputation injuries were excluded. Mild artery defect or partial intimal damage was treated by interventional implantation, while other patients received open surgeries, including direct suture of small defect less than 2 cm and transplantation with autologous vein or artificial blood when the defect was more than 2 cm. Patients were divided into open surgery group and stent implantation group based on the treatment they received. Patients were followed up at 2 weeks (first stage) and 6 months (second stage) after operation to investigate limb salvage. Student's t-test was used to compare the general data between two groups and Chi-square test to analyze the rate of limb salvage. RESULTS: Altogether 50 cases of subclavian artery injury were treated, including 36 cases of open surgery and 14 cases of stent implantation. Combination of nerve injury was observed in 27 cases (75.0%) in open surgery group and 12 cases (85.7%) in stent implantation group. Amputation developed in 3 cases with open surgery and 1 case with stent implantation. Consequently the rate of successful limb salvage was respectively 91.7% (33/36) and 92.9% (13/14), revealing no significant difference (p > 0.05). CONCLUSION: Rapid reconstruction of blood circulation is crucial following subclavian artery injury, no matter what kinds of treatment strategies have been adopted. Interventional stent implantation can achieve a good effect for limb salvage.

Literature review of peripheral vascular trauma: Is the era of intervention coming?

Traumatic peripheral vascular injury is a significant cause of disability and death either in civilian environments or on the battlefield. Penetrating trauma and blunt trauma are the most common forms of vascular injuries. Besides, iatrogenic arterial injury (IAI) is another pattern of vascular trauma. The management of peripheral vascular injuries has been improved in different environments and wars. There are different types of vascular injuries, such as vasospasm, contusion, intimal flaps, intimal disruption or hematoma, external compression, laceration, transection and focal wall defects, etc. The main clinical manifestations of vascular injuries are shock following massive hemorrhage and limb necrosis due to tissue and organ ischemia. Ultrasound, computed tomography angiography (CTA) and magnetic resonance angiography (MRA) are most valuable for assessment of peripheral vascular injuries. Angiography remains the gold standard for diagnosing vascular trauma. Immediate hemorrhage control and rapid restoration of blood flow are the primary goals of vascular trauma treatment. There are many operative treatment methods for vascular injuries, such as vascular suture or ligation, vascular wall repair and vascular reconstruction with blood vessel prostheses or vascular grafts. Embolization, balloon dilation and covered stent implantation are the main endovascular techniques. Surgical operation is still the primary treatment for vascular injuries. Endovascular treatment is a promising alternative, proved to be safe and effective, and preferred selection for patients. In summary, rapid diagnosis and timely surgical intervention remain the mainstays of the treatment. However, many issues need to be resolved by further studies.

Clinical outcomes of AngioJet pharmacomechanical thrombectomy versus catheter-directed thrombolysis for the treatment of filter-related caval thrombosis.

BACKGROUND: The inferior vena cava filter is utilized worldwide to intercept thrombi and to reduce the risk of fatal pulmonary embolism (PE). However, filter-related thrombosis is a complication of filter implantation. Endovascular methods such as AngioJet rheolytic thrombectomy (ART) and catheter-directed thrombolysis (CDT) can treat filter-related caval thrombosis, but the clinical outcomes of both treatment modalities have not been determined. AIM: To compare the treatment outcomes of AngioJet rheolytic thrombectomy vs catheter-directed thrombolysis in patients with filter-related caval thrombosis. METHODS: In this single-center retrospective study, 65 patients (34 males and 31 females; mean age: 59.0 ± 13.43 years) with intrafilter and inferior vena cava thrombosis were enrolled between January 2021 and August 2022. These patients were assigned to either the AngioJet group (n = 44) or the CDT group (n = 21). Clinical data and imaging information were collected. Evaluation measures included thrombus clearance rate, periprocedural complications, urokinase dosage, incidence of PE, limb circumference difference, length of stay, and filter removal rate. RESULTS: Technical success rates were 100% in the AngioJet and CDT groups. In the AngioJet group, grade II and grade III thrombus clearance was achieved in 26 (59.09%) and 14 (31.82%) patients, respectively. In the CDT group, grade II and grade III thrombus clearance was accomplished in 11 (52.38%) patients and 8 (38.10%) patients, respectively (P > 0.05).The peridiameter difference of the thigh was significantly reduced in patients from both groups after treatment (P < 0.05). The median dosage of urokinase was 0.08 (0.02, 0.25) million U in the AngioJet group and 1.50 (1.17, 1.83) million U in the CDT group (P < 0.05). Minor bleeding was shown in 4 (19.05%) patients in the CDT group, and when it was compared with that in the AngioJet group, the difference was statistically significant (P < 0.05). No major bleeding occurred. Seven (15.91%) patients in the AngioJet group had hemoglobinuria and 1 (4.76%) patient in the CDT group had bacteremia. There were 8 (18.18%) patients with PE in the AngioJet group and 4 (19.05%) patients in the CDT group before the intervention (P > 0.05). Computed tomography angiopulmonography (CTA) showed that PE was resolved after the intervention. New PE occurred in 4 (9.09%) patients in the AngioJet group and in 2 (9.52%) patients in the CDT group after theintervention (P > 0.05). These cases of PE were asymptomatic. The mean length of stay was longer in the CDT group (11.67 ± 5.34 d) than in the AngioJet group (10.64 ± 3.52 d) (P < 0.05). The filter was successfully retrieved in the first phase in 10 (47.62%) patients in the CDT group and in 15 (34.09%) patients in the AngioJet group (P > 0.05).Cumulative removal was accomplished in 17 (80.95%) out of 21 patients in the CDT group and in 42 (95.45%) out of 44 patients in the ART group (P > 0.05). The median indwelling time for patients with successful retrieval was 16 (13139) d in the CDT group and 59 (12231) d in the ART group (P > 0.05). CONCLUSION: Compared with catheter-directed thrombolysis, AngioJet rheolytic thrombectomy can achieve similar thrombus clearance effects, improve the filter retrieval rate, reduce the urokinase dosage and lower the risk of bleeding events in patients with filter-related caval thrombosis.

Genomewide association study of leprosy.

BACKGROUND: The narrow host range of Mycobacterium leprae and the fact that it is refractory to growth in culture has limited research on and the biologic understanding of leprosy. Host genetic factors are thought to influence susceptibility to infection as well as disease progression. METHODS: We performed a two-stage genomewide association study by genotyping 706 patients and 1225 controls using the Human610-Quad BeadChip (Illumina). We then tested three independent replication sets for an association between the presence of leprosy and 93 single-nucleotide polymorphisms (SNPs) that were most strongly associated with the disease in the genomewide association study. Together, these replication sets comprised 3254 patients and 5955 controls. We also carried out tests of heterogeneity of the associations (or lack thereof) between these 93 SNPs and disease, stratified according to clinical subtype (multibacillary vs. paucibacillary). RESULTS: We observed a significant association (P<1.00x10(-10)) between SNPs in the genes CCDC122, C13orf31, NOD2, TNFSF15, HLA-DR, and RIPK2 and a trend toward an association (P=5.10x10(-5)) with a SNP in LRRK2. The associations between the SNPs in C13orf31, LRRK2, NOD2, and RIPK2 and multibacillary leprosy were stronger than the associations between these SNPs and paucibacillary leprosy. CONCLUSIONS: Variants of genes in the NOD2-mediated signaling pathway (which regulates the innate immune response) are associated with susceptibility to infection with M. leprae.