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.

Effects of moxibustion with wheat-grain size cone at "Zusanli" (ST 36) on vascular injury and oxidative stress in high-fat diet rats through mTOR/HIF-1α/VEGF signaling pathway. / 基于mTOR/HIF-1α/VEGF信号通路探讨麦粒灸"足三里"å¯¹é«˜è„‚é¥®é£Ÿå¤§é¼ è¡€ç®¡æŸä¼¤å’Œæ°§åŒ–åº”æ¿€çš„å½±å“.

OBJECTIVES: To explore the effect mechanism of moxibustion with wheat-grain size cone at "Zusanli" (ST 36) on vascular injury and oxidative stress in hyperlipidemia through mammalian target of rapamycin (mTOR)/hypoxia inducible factor-1α (HIF-1α)/vascular endothelial growth factor (VEGF) signaling pathway. METHODS: Forty healthy male SD rats with SPF grade were randomly divided into a normal group, a model group, a moxibustion group, and an inhibitor group, with 10 rats in each one. The hyperlipidemia model was established by feeding a high-fat diet for 8 weeks in rats of the model group, the moxibustion group and the inhibitor group. The moxibustion with wheat-grain size cone was delivered at bilateral "Zusanli" (ST 36) of each rat in the moxibustion group and the inhibitor group, with 3 cones on each acupoint in each intervention, once daily for 4 weeks. In the inhibitor group, before each intervention with moxibustion, rapamycin solution was injected intraperitoneally, 2.0 mg/kg. After modeling and intervention, using ELISA, the levels of total cholesterol (TC), triglyceride (TG), high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C) in the serum of rats were determined. After intervention, with HE staining and oil red O staining adopted, the abdominal aortic morphology and peripheral lipid deposition were observed. Separately, using WST-1, TBA and micro-plate method, the superoxide dismutase (SOD) activity and the levels of malondialdehyde (MDA) and nitric oxide (NO) in the serum were detected. The protein expression of mTOR, HIF-1α and VEGF in abdominal aorta were measured by Western blot method. RESULTS: Compared with those in the normal group, the levels of TC, TG and LDL-C increased (P<0.01) and HDL-C decreased (P<0.01) in the serum of the rats in the model group, the moxibustion group and the inhibitor group after model establishment. When compared with the normal group after intervention, in the model group, the serum levels of TC, TG, LDL-C and MDA increased (P<0.01), HDL-C level, SOD activity and NO level were reduced (P<0.01); the cell structure of the abdominal arota was abnormal, the peripheral lipids deposited seriously; and the protein expression of mTOR, HIF-1α and VEGF of abdominal aorta was elevated (P<0.01, P<0.05). In comparison with the model group, the levels of TC, TG, LDL-C and MDA were reduced (P<0.01), HDL-C levels, SOD activities and NO levels elevated (P<0.01, P<0.05), as well as the protein expression of mTOR, HIF-1α and VEGF of abdominal aorta (P<0.01, P<0.05) in the moxibustion group and the inhibitor group; besides, the vascular structure was ameliorated and the lipid deposition reduced in the moxibustion group, while, the vascular structure was still abnormal and the lipid deposition declined in the inhibitor group. When compared with the inhibitor group, the serum SOD activity and NO level increased (P<0.05) and MDA decreased (P<0.05); and the protein expression of mTOR, HIF-1α and VEGF of abdominal aorta was elevated (P<0.01, P<0.05) in the moxibustion group. CONCLUSIONS: The vascular injury due to hyperlipidemia is repaired by moxibustion with wheat-grain size cone at "Zusanli" (ST 36) through ameliorating oxidative stress, which is associated potentially with the modulation of mTOR/HIF-1α/VEGF signaling pathway.

Liquid plasma promotes angiogenesis through upregulation of endothelial nitric oxide synthase-induced extracellular matrix metabolism: potential applications of liquid plasma for vascular injuries.

BACKGROUND: Applications of nonthermal plasma have expanded beyond the biomedical field to include antibacterial, anti-inflammatory, wound healing, and tissue regeneration. Plasma enhances epithelial cell repair; however, the potential damage to deep tissues and vascular structures remains under investigation. RESULT: This study assessed whether liquid plasma (LP) increased nitric oxide (NO) production in human umbilical vein endothelial cells by modulating endothelial NO synthase (eNOS) phosphorylation and potential signaling pathways. First, we developed a liquid plasma product and confirmed the angiogenic effect of LP using the Matrigel plug assay. We found that the NO content increased in plasma-treated water. NO in plasma-treated water promoted cell migration and angiogenesis in scratch and tube formation assays via vascular endothelial growth factor mRNA expression. In addition to endothelial cell proliferation and migration, LP influenced extracellular matrix metabolism and matrix metalloproteinase activity. These effects were abolished by treatment with NG-L-monomethyl arginine, a specific inhibitor of NO synthase. Furthermore, we investigated the signaling pathways mediating the phosphorylation and activation of eNOS in LP-treated cells and the role of LKB1-adenosine monophosphate-activated protein kinase in signaling. Downregulation of adenosine monophosphate-activated protein kinase by siRNA partially inhibited LP-induced eNOS phosphorylation, angiogenesis, and migration. CONCLUSION: The present study suggests that LP treatment may be a novel strategy for promoting angiogenesis in vascular damage. Video Abstract.

Adventitial delivery of miR-145 to treat intimal hyperplasia post vascular injuries through injectable and in-situ self-assembling peptide hydrogels.

Intimal hyperplasia is a common lesion that can be observed in diverse vascular diseases. Drug-eluting stents and drug-coated balloons, which can release anti-proliferative agents to inhibit smooth muscle cell (SMC) proliferation, are developed to prevent intimal hyperplasia. However, these intervention devices still cannot achieve satisfactory clinical outcomes. In contrast to endovascular drug delivery, vascular adventitial drug delivery is a new strategy. To develop a vascular adventitial drug delivery system to treat intimal hyperplasia post vascular injuries, we loaded miR-145-5p-agomir (miR-145) into an injectable and in-situ self-assembling RAD peptide hydrogel. In vitro data showed that the miR-145 could be well incorporated into the RAD peptide hydrogels and released in a slow and controlled manner. The released miR-145 could transfect SMCs successfully, and the transfected SMCs exhibited a reduced migration capacity and higher expressions of SMC contractile biomarkers as compared to the non-transfected SMCs. In vivo data showed that the retention of the miR-145 was greatly elongated by the RAD peptide hydrogels. In addition, the application of the miR-145-loaded RAD peptide hydrogels surrounding injured arteries decreased the proliferative SMCs, promoted the regeneration of endothelium, reduced the macrophage infiltration, inhibited the neointimal formation and prevented adverse ECM remodeling via downregulation of KLF4 expression. The RAD peptide hydrogels loaded with miR-145 can successfully inhibit intimal hyperplasia after vascular injuries and thus hold great potential as an innovative extravascular drug delivery approach to treat vascular diseases. STATEMENT OF SIGNIFICANCE: Intimal hyperplasia is a common lesion that can be observed in diverse vascular diseases. Drug-eluting stents and drug-coated balloons, which can release anti-proliferative agents to inhibit smooth muscle cell (SMC) proliferation, are developed to prevent intimal hyperplasia. However, these intervention devices still cannot achieve satisfactory clinical outcomes. In contrast to endovascular drug delivery, vascular adventitial drug delivery is a new strategy. Our work here demonstrates that the RAD peptide hydrogels loaded with miR-145-5p-agomir (miR-145) can successfully reverse intimal hyperplasia after vascular injuries and thus hold great potential as an innovative vascular adventitial drug delivery approach to treat vascular diseases. Our work proposes a possible paradigm shift from endovascular drug delivery to extravascular drug delivery for vascular disorder treatment.

Traumatic Iliac Arteriovenous Fistula Treated With the Amplatzer Vascular Plug II: A Case Report and Literature Review.

Traumatic iliac arteriovenous fistula is a rare complication of vascular injury. Open surgical repair has an incidence of postoperative complications. In recent years, endovascular treatment has shown better efficacy. We report a 62-year-old female AVF patient with a stab injury history of more than 16 years. Computed tomography angiography (CTA) revealed a large arteriovenous fistula between the right internal iliac artery and the common iliac vein. After considering the patient's relevant conditions, an endovascular approach was satisfactorily performed with the implantation of an Amplatzer Vascular Plug II to interrupt the abnormal vascular communication and maintain arterial and venous patency. The final control images showed closure of the arteriovenous communication.

32-year-old Traumatic Arteriovenous Fistula Presenting With Leg Ulcer and High-output Heart Failure.

Traumatic arteriovenous fistula (AVF) is not a common disorder, and dermatological signs and heart failure caused by AVF are rarely reported. We present the case of a 55-year-old woman who was referred for congestive heart failure symptoms. Echocardiography revealed preserved left ventricular ejection fraction. Due to edema of the right leg with a long-standing leg ulcer and palpable femoral thrill, duplex ultrasonography was performed. It showed an AVF between the right superficial femoral artery (SFA) and the right femoral vein (FV). The patient recalled a 32-year-old gunshot injury that was not medically treated. After the diagnosis of AVF she was referred to a surgeon for an AVF ligation, with subsequent resolution of her symptoms. The differential diagnosis of leg ulcer with leg edema should include the possibility of AVF as a cause.

Systematic Review and Meta-Analysis of Nonoperative Management for SVS Grade II Blunt Traumatic Aortic Injury.

BACKGROUND: Society for Vascular Surgery (SVS) grade II blunt traumatic aortic injury is defined as intramural hematoma with or without external contour abnormality. It is uncertain whether this aortic injury pattern should be treated with endovascular stent-grafting or nonoperative measures. Since the adoption of the SVS Guidelines on endovascular repair of blunt traumatic aortic injury, the practice pattern for management of grade II injuries has been heterogenous. The objective of the study was to report natural history outcomes of grade II blunt traumatic aortic injury. METHODS: A systematic review of published traumatic aortic injury studies was performed. Online database searches were current to November 2022. Eligible studies included data on aortic injuries that were both managed nonoperatively and classified according to the SVS 2011 Guidelines. Data points on all-cause mortality, aorta-related mortality and early aortic intervention were extracted and underwent meta-analysis. The methodology was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance. RESULTS: Thirteen studies were included in the final analysis with a total of 204 cases of SVS grade II blunt traumatic aortic injury treated nonoperatively. The outcomes rates were estimated at 10.4% (95% confidence interval [CI] 6.7%-14.9%) for all-cause mortality, 2.9% (95% CI 1.1%-5.7%) for aorta-related mortality, and 3.3% (95% CI 1.4%-6.2%) for early aortic intervention. The studies included in the analysis were of fair quality with a mean Downs and Black score 15 (±1.8). CONCLUSIONS: Grade II blunt traumatic aortic injury follows a relatively benign course with few instances of aortic-related mortality. Death in the setting of this injury pattern is more often attributable to sequelae of multisystem trauma and not directly related to aortic injury. The current data support nonoperative management and imaging surveillance for grade II blunt traumatic aortic injury instead of endovascular repair. Longer-term effects on the aorta at the site of injury are unknown.

Prehospital tourniquet application in extremity vascular trauma: Improved functional outcomes.

BACKGROUND: Support for prehospital tourniquet use has increased, with recent data suggesting that tourniquet usage decreases shock without increasing limb complications. We hypothesized that prehospital tourniquet application in extremity vascular trauma, compared with no prehospital tourniquet application, is associated with lower rates of delayed amputation and better functional mobility. METHODS: We retrospectively studied adult patients with extremity vascular trauma at an urban civilian Level 1 trauma center (June 2016-May 2021). Outcomes of interest included delayed amputation and mobility at hospital discharge, measured by the Activity Measure for Post-Acute Care "6 Clicks" Basic Mobility Score. The "6 Clicks" Basic Mobility Score was documented by physical therapy; higher scores indicate more independent mobility. Injury mechanism, initial lactate, 24-hour transfusions, mortality, and acute kidney injury were also collected. Comparisons were performed using χ2 analysis and Fisher Exact and Wilcoxon rank-sum tests. RESULTS: Of 232 patients, prehospital tourniquet application was not associated with mortality or lactate level (both P > .05). The prehospital tourniquet application group had more transfusions, lower rates of acute kidney injury, and fewer delayed amputations (all P < .05). Ninety-one patients (45 prehospital tourniquet application and 46 without prehospital tourniquet application) were evaluated for "Moving between Bed and Chair" in the "6 Clicks" Basic Mobility Score, with patients in the prehospital tourniquet application group demonstrating higher levels of independence (P = .034). CONCLUSION: Prehospital tourniquet application was associated with favorable outcomes, including higher functional mobility and decreased delayed amputation. This suggests that tourniquet use should be encouraged in the civilian setting to improve outcomes and reduce the risk of limb loss.

Endovascular Management of Iatrogenic Arterial Injuries after Orthopedic Surgery of the Lower Limb.

PURPOSE: To evaluate the safety and effectiveness of embolization, and to identify the contributory factors of failures in patients treated for iatrogenic arterial injuries after orthopedic surgery of the lower limb. MATERIALS AND METHODS: In this retrospective study, data from patients treated from December 2008 to March 2022 for an arterial injury due to orthopedic surgery of the lower limb were analyzed from a single center. Demographic, clinical, and procedure-related data were collected. Perioperative and 30-day mortalities were estimated. Odds ratios and hazard ratios were calculated for several potential risk factors: age of >75 years, atherosclerosis, preexisting infection, urgency of surgery (trauma vs elective), previous surgery, multiple distant injuries, and multiple vascular supplies to the same injury. RESULTS: Eighty-six procedures performed on 78 patients were included in the study. The rates of technical and clinical success were 100% and 92.3%, respectively. Six (7.7%) patients were retreated because of persistent bleeding. The perioperative mortality was 1.3%, and the 30-day mortality rate was 7.7%. The presence of multiple arterial supplies, multiple injuries, previous surgery, presence of atherosclerosis, or a preexisting musculoskeletal infection resulted in a higher risk of retreatment. CONCLUSIONS: Embolization is safe and effective in the management of iatrogenic arterial injuries after orthopedic surgery. The number of involved vascular territories was the most critical factor in determining technical failure.

Rise in Percutaneous Vascular Procedures and Extracorporeal Membrane Oxygenation Is Associated With Increase in Emergent Vascular Operations.

Background: The workload of vascular surgeons is widely affected by the procedural activity of other departments within the same medical center. The purpose of this study was to evaluate the trend in emergent vascular surgery procedures over a 5 year period in a tertiary referral hospital and categorize these procedures based on the nature of the operative procedure required. Methods: A single center, retrospective review of all emergent surgical operations performed at our tertiary referral hospital between the years 2017-2021. Data collected included types of emergent vascular surgery performed, in addition to procedures performed by the departments of interventional cardiology (IC), interventional radiology (IR), neurointerventional radiology (NIR) and extracorporeal membrane oxygenation (ECMO) at our institution. Results: During the study period were performed a total of 1783 operative procedures (mean 356 ± 26/year). Of those, 485 (27%) were emergent cases. We observed a gradual increase in emergent operative procedures performed from 2017 to 2021 (22% to 34% of all cases, increase of 56%, P<.01). A striking increase was seen with vascular repairs performed for iatrogenic vascular injuries secondary to arterial access complications (47% to 65% of all iatrogenic vascular injuries, increase of 38%). The increase correlated with an increase in activity seen in the departments of IC, IR/NIR and ECMO (15%, 31% and 300%, respectively). Conclusions: An increasing number of emergent surgical procedures performed by our vascular surgery department correlates with the increasing number of endovascular procedures performed by non- vascular services. As these procedures are expected to increase, together with the number of stroke units and ECMO units being created, medical centers must be aware that these may result in a significant increase in the workload of the vascular surgery department in order to deal with complications associated with these procedures.

Expedient Endovascular Hemorrhage Control During Anterior Lumbar Spinal Exposure Allows Procedural Completion in Rescued Patients.

OBJECTIVES: To propose a contemporary management strategy for venous injury during anterior lumbar spinal exposure that incorporates endovascular treatment. METHODS: Vein injuries suffered by patients treated in a single practice were reviewed. A treatment algorithm based on these experiences was formulated. RESULTS: Between 2015 and 2018, 914 patients received anterior access procedures for indicated lumbar interbody fusions. Of these patients, 15 (1.6%) suffered minor vascular injuries treated with manual pressure or suture repair. Four (0.4%) patients undergoing anterior lumbar spine surgery suffered major venous injuries, all of whom received the indicated spinal hardware following endovascular rescue. Primary repair was attempted in three patients before endovascular control and not at all in one. Vascular access was obtained via the bilateral femoral veins in 2 patients, unilateral femoral in one, and bilateral femoral plus right internal jugular vein in one. Stent choice included both uncovered (5, 63%) and covered stents (3, 38%). Deep venous thrombosis occurred in 2 patient's post-treatment. 1 DVT was encountered in the setting of a covered stent and 1 uncovered stent thrombosis was treated with catheter-directed lysis 4 weeks post-operatively. Ultimately, 3 patients were therapeutically anticoagulated. Mean follow-up is 13 months (range 1-36) with duplex ultrasounds available at 6 months or later in 3 of 4 patients. There is no evidence of post-thrombotic syndrome in the 2 patients that developed DVT's or in-stent stenosis in the 3 patients with available follow-up imaging. CONCLUSIONS: Endovascular techniques are important adjuncts when controlling large-volume hemorrhage associated with venous tears during anterior spinal exposure. Adequate direct compression allowing occlusion balloon inflation are key steps to reduce blood loss. Covered and uncovered stents are both appropriate choices to treat injuries. Patients must be anticoagulated post-operatively and surveilled for the sequelae of venous insufficiency. With expedient hemostasis, the indicated spinal surgery may be safely completed.

The use of a Foley balloon catheter to control junctional hemorrhage in a dog with severe vascular injury secondary to penetrating trauma.

INTRODUCTION: Penetrating trauma is commonly seen in dogs. The severity depends on the site of injury and tissue involved. Junctional hemorrhage can be especially challenging to control given the inaccessibility of the damaged vasculature. Methods described to control life-threatening hemorrhage in dogs include direct pressure, hemostatic gauze, hemostatic powder or granules, wound packing, tourniquets, and direct clamping of the vasculature. Foley balloon catheters (FBC) are commonly used to tamponade deep vascular hemorrhage in people, but the technique has not been previously described in the veterinary literature. OBJECTIVE: To present a case of penetrating trauma (bite wound) in a dog with a transected left femoral artery and vein in which the life-threatening hemorrhage was initially controlled with tamponade using an FBC. CASE: A 7-year-old neutered male Terrier mix presented in hemorrhagic shock with an Animal Trauma Triage (ATT) of 7 and modifed Glasgow coma scale (MGCS) of 17 forty-five minutes after being attacked by another dog. The dog had sustained a deep penetrating wound to the left groin. Direct pressure and gauze packing at the site of injury were not successful at slowing the hemorrhage. A 10-Fr, 55-cm Foley catheter with a 5-mL balloon was inserted into the wound tract, and the balloon was inflated with 7.5 mL of sterile saline. Hemorrhage was controlled after inflation of the Foley balloon. CBC, blood biochemistries, abdominal point-of-care ultrasound, radiographs, prothrombin time, partial thromboplastin time, and whole blood viscoelastic testing were performed. Stabilization included fluid resuscitation, analgesics, antimicrobials, and epsilon aminocaproic acid. The dog was then anesthetized to definitively identify and control the hemorrhage. Transection of the left femoral artery and vein where identified and ligated. The dog fully recovered and was discharged 32 hours later. NEW AND UNIQUE INFORMATION: FBCs may be useful as an alternative technique for temporary control of life-threatening hemorrhage secondary to penetrating injuries in both the emergency department and prehospital settings.

The tight rope act: A multicenter regional experience of tourniquets in acute trauma resuscitation.

BACKGROUND: As tourniquets have become more prevalent, device use has been questioned. This study sought to characterize the incidence, indication, and efficacy of tourniquet placement in acute trauma resuscitation. METHODS: Nine regional level 1 trauma centers prospectively enrolled for 12 months adult patients (18 years or older) who had a tourniquet placed. Age, sex, mechanism, tourniquet type, indication, applying personnel, location placed, level of occlusion, and degree of hemostasis were collected. Major vascular injury, imaging and operations performed, and outcomes were assessed. Analyses were performed with significance at p < 0.05. RESULTS: A total of 216 tourniquet applications were reported on 209 patients. There were significantly more male patients (183 [88%]) and penetrating injuries (186 [89%]) with gunshots being most common (127 [61%]). Commercial tourniquets were most often used (205 [95%]). Ninety-two percent were placed in the prehospital setting (by fire/paramedics, 56%; police, 33%; bystanders, 2%). The most common indications were pooling (47%) and pulsatile (32%) hemorrhage. Only 2% were for amputation. The most frequent location was high proximal extremity (70%). Four percent were placed over the wound, and 0.5% were distal to the wound. Only 61% of applications were arterial occlusive. Median application time was 30 minutes (interquartile range, 20-40 minutes). Imaging was performed in 54% of patients. Overall, 36% had a named arterial injury. Tourniquet application failed to achieve hemostasis in 22% of patients with a named vascular injury. There was no difference in hemostasis between those with and without vascular injury (p = 0.12) or between who placed the tourniquet (p = 0.07). Seventy patients (34%) required vascular operations. Thirty-four percent of patients were discharged home without admission. CONCLUSION: Discerning which injuries require tourniquets over pressure dressings remains elusive. Trained responders had high rates of superfluous and inadequate deployments. As tourniquets continue to be disseminated, emphasis should be placed on improving education, device development, and quality control. LEVEL OF EVIDENCE: Prognostic/Epidemiologic, Level III.

Post-Tracheostomy Vascular Injury to the Anomalous Thymic Branch Managed by Endovascular Coiling.

BACKGROUND: Tracheostomy-related arterial haemorrhage can be devastating especially if arising from an obscure anomalous vessel which can potentially complicate treatment decision. METHODS: We report a case of non-Hodgkin's lymphoma with upper airway obstruction, who had profuse bleeding, post-tracheostomy, from the stomal site. CT angiography showed presence of a pseudoaneurysm adjacent to the tracheostomy site which was confirmed on catheter angiography to be arising from anomalous thymic branch of right common carotid artery (CCA). Superselective cannulation of the anomalous thymic artery was done using a microcatheter with subsequent coil embolization. RESULTS: Post-coiling, the bleeding stopped immediately and the patient recovered. He was under oncology care till 3 months following embolization and was doing well. CONCLUSIONS: The emergency physicians should be aware of this rare variation of thymic artery while performing tracheostomy. Ultrasound as point-of-care device may help mitigate these complications. Endovascular embolization is a minimally invasive and effective management option for an injured arterial branch from a tracheostomy.

Controversies in Surgery: Trauma.

As care of the injured patient continues to evolve, new surgical technologies and new resuscitative therapies can change the algorithms that drive trauma care. In particular, the advent of resuscitative endovascular balloon occlusion of the aorta has changed the way trauma surgeons treat patients in extremis. The science of resuscitation continues to evolve, leading to controversy about the optimal administration of fluid and blood products. Laparoscopy has given additional tools to the trauma surgeon to potentially avoid exploratory laparotomy, and rib fracture fixation can be beneficial in the proper patient.

Endovascular management of subclavian-steal syndrome in a patient with post-traumatic dissection of an aberrant right subclavian artery.

BACKGROUND: An aberrant right subclavian artery is the most common congenital anomaly of the aortic arch and may cause symptoms due to aneurysmal dilatation, stenosis or occlusion. We present a case of subclavian-steal syndrome due to post-traumatic dissection of an aberrant right subclavian artery. METHODS AND RESULTS: A 50 year-old man presented with dizziness and fainting episodes after exercising his right arm and a systolic blood pressure gradient of 40 mm Hg between the 2 arms. Suspecting a subclavian steal syndrome, a computed tomography angiography was requested which revealed an aberrant right subclavian artery with a severe stenosis proximal to the ostium of the vertebral artery. Transfemoral digital subtraction angiography showed a local dissection of the aberrant right subclavian artery with late retrograde filling of the ipsilateral vertebral artery. The lesion was successfully treated with primary stent implantation (9 mm x 40 mm, LIFESTAR, BARD). On interrogation, the patient recalled an injury to the right arm after falling off a ladder 10 years earlier, as a possible post-traumatic cause for the dissection. He had an uneventful outcome and is symptom-free 12 months down the line. CONCLUSIONS: The combination of post-traumatic dissection of an aberrant right subclavian artery resulting to subclavian steal syndrome is an extremely rare scenario. Endovascular management is a safe, minimally invasive alternative to open surgery.

Hemodynamically unstable non-compressible penetrating torso trauma: a practical surgical approach.

Penetrating torso trauma is the second leading cause of death following head injury. Traffic accidents, falls and overall blunt trauma are the most common mechanism of injuries in developed countries; whereas, penetrating trauma which includes gunshot and stabs wounds is more prevalent in developing countries due to ongoing violence and social unrest. Penetrating chest and abdominal trauma have high mortality rates at the scene of the incident when important structures such as the heart, great vessels, or liver are involved. Current controversies surround the optimal surgical approach of these cases including the use of an endovascular device such as the Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) and the timing of additional imaging aids. This article aims to shed light on this subject based on the experience earned during the past 30 years in trauma critical care management of the severely injured patient. We have found that prioritizing the fact that the patient is hemodynamically unstable and obtaining early open or endovascular occlusion of the aorta to gain ground on avoiding the development of the lethal diamond is of utmost importance. Damage control surgery starts with choosing the right surgery of the right cavity in the right patient. For this purpose, we present a practical and simple guide on how to perform the surgical approach to penetrating torso trauma in a hemodynamically unstable patient.

El trauma penetrante del torso representa la segunda causa de muerte de origen traumático después del trauma craneoencefálico. En países desarrollados existe mayor prevalencia de trauma cerrado, asociado principalmente a accidentes de tránsito o caídas de grandes alturas. Mientas, que en países en vía de desarrollo el trauma penetrante es más prevalente con heridas por arma de fuego o por arma blanca asociado a la violencia y las desigualdades sociales. El trauma penetrante torácico y abdominal pueden presentar altas tasas de mortalidad en la escena del trauma si se comprometen estructuras importantes como el corazón, los grandes vasos o el hígado. Actualmente, existen controversias sobre el adecuado abordaje quirúrgico con la implementación o no de dispositivos endovasculares como el balón de resucitación endovascular de oclusión aórtica (Resuscitative Endovascular Balloon Oclussion of the Aorta - REBOA) y la realización de ayudas imagenológicas. El objetivo de este artículo es presentar el conocimiento sobre este tema, basado en la experiencia adquirida durante los últimos 30 años con el manejo del trauma, cirugía general y cuidado crítico. Sostenemos que en un paciente hemodinámicamente inestable se debe realizar una temprana oclusión aórtica endovascular o abierta con el objetivo de evitar el desarrollo o propagación del rombo de la muerte. Con este propósito, presentamos una guía práctica y sencilla sobre el abordaje quirúrgico del paciente hemodinámicamente inestable con trauma penetrante del torso.

Proximal splenic embolisation versus distal splenic embolisation for management of focal distal arterial injuries of the spleen.

INTRODUCTION: To compare the outcomes of proximal (pSAE) versus distal (dSAE) splenic artery embolisation for management of focal distal arterial splenic injuries secondary to blunt splenic trauma. METHOD: Ethical approval was granted by the hospital research and ethics committee, Project 389/19. All patients who underwent splenic artery embolisation secondary to blunt abdominal trauma from 1 January 2009 to 1 January 2019 were reviewed. Patients with a tandem embolisation (both proximal and distal embolisations) or those with no acute vascular injury on angiography were excluded. Patient demographics, injury type/ AAST grade (2018 classification), technique of embolisation and outcomes were collected. Complications and splenectomy rates up to 30 days were recorded. RESULTS: 136 out of 232 patients had an embolisation performed for a distal vascular injury including active arterial bleeding, pseudoaneurysm or arteriovenous fistula. Mean age was 41 (range 16-84). Mean AAST grade was 4 (range 3-5). Mean Injury Severity Score was 22. pSAE was performed in 79.4% (n = 108) and dSAE in 20.6% (n = 28). Major complications occurred in 12 patients (pSAE n = 12, 11.1%; dSAE n = 0, P > 0.05); 6 pSAE required splenectomy (n = 6, 5.6%). There was no significant difference in outcomes between the two groups or when based on AAST grading. CONCLUSION: No significant difference was observed between proximal and distal embolisation techniques for blunt trauma patients with a distal vascular injury in terms of technical and clinical success.