Systematic review and meta-analysis of endovascular therapy versus open surgical repair for the traumatic lower extremity arterial injury.

OBJECTIVE: For traumatic lower extremity artery injury, it is unclear whether it is better to perform endovascular therapy (ET) or open surgical repair (OSR). This study aimed to compare the clinical outcomes of ET versus OSR for traumatic lower extremity artery injury. METHODS: The Medline, Embase, and Cochrane Databases were searched for studies. Cohort studies and case series reporting outcomes of ET or OSR were eligible for inclusion. Robins-I tool and an 18-item tool were used to assess the risk of bias. The primary outcome was amputation. The secondary outcomes included fasciotomy or compartment syndrome, mortality, length of stay and lower extremity nerve injury. We used the random effects model to calculate pooled estimates. RESULTS: A total of 32 studies with low or moderate risk of bias were included in the meta-analysis. The results showed that patients who underwent ET had a significantly decreased risk of major amputation (OR = 0.42, 95% CI 0.21-0.85; I2=34%) and fasciotomy or compartment syndrome (OR = 0.31, 95% CI 0.20-0.50, I2 = 14%) than patients who underwent OSR. No significant difference was observed between the two groups regarding all-cause mortality (OR = 1.11, 95% CI 0.75-1.64, I2 = 31%). Patients with ET repair had a shorter length of stay than patients with OSR repair (MD=-5.06, 95% CI -6.76 to -3.36, I2 = 65%). Intraoperative nerve injury was just reported in OSR patients with a pooled incidence of 15% (95% CI 6%-27%). CONCLUSION: Endovascular therapy may represent a better choice for patients with traumatic lower extremity arterial injury, because it can provide lower risks of amputation, fasciotomy or compartment syndrome, and nerve injury, as well as shorter length of stay.

Peroneal artery injury potential due to different syndesmosis screw placement options: a simulation study with lower extremity computed tomography angiography.

INTRODUCTION: The aim of this study is to assess the risk of peroneal artery injury of hardware placement at the fixation of syndesmotic injuries. MATERIALS AND METHODS: The lower extremity computed tomography angiography was used to design the study. The syndesmosis screw placement range was simulated every 0.5 cm, from 0.5 to 5 cm proximal to the ankle joint. The screw axes were drawn as 20°, 30° or individual angle according to the femoral epicondylar axis. The proximity between the screw axis and the peroneal artery was measured in millimeters. Potential peroneal artery injury was noted if the distance between the peroneal artery to the axis of the simulated screw was within the outer shaft radius of the simulated screw. The Pearson chi-square test was used and a p-value < 0.05 was considered significant. RESULTS: The potential for injury to the peroneal artery increased as the syndesmosis screw level rose proximally from the ankle joint level or as the diameter of the syndesmosis screw increasds. In terms of syndesmosis screw trajection, the lowest risk of injury was observed with the syndesmosis screw angle of 20°. Simulations with a screw diameter of 3.5 mm exhibited the least potential for peroneal artery injury. CONCLUSION: Thanks to this radiological anatomy simulation study, we believe that we have increased the awareness of the peroneal artery potential in syndesmosis screw application. Each syndesmosis screw placement option may have different potential for injury to the peroneal artery. To decrease the peroneal artery injury potential, we recommend the followings. If individual syndesmosis screw angle trajection can be measured, place the screw 1.5 cm proximal to the ankle joint using a 3.5 mm screw shaft. If not, fix it with 30° trajection regardless of the screw diameter at the same level. If the most important issue is the peroneal artery circulation, use the screw level up to 1 cm proximal to the ankle joint regardless of the screw angle trajection and screw diameter.

Emergency vascular repairs in trauma: Predictors of poor prognosis and a novel scoring system.

BACKGROUND: Vascular injuries comprise 1% to 4% of all trauma patients, and there are no widely used risk-stratification tools. We sought to establish predictors of revascularization failures and compare outcomes of trauma and vascular surgeons. METHODS: We performed a single-institution, case-control study of consecutive patients with traumatic arterial injuries who underwent open repair between 2016 and 2021. Multivariable logistic regression was used to investigate covariates impacting the primary composite outcome of repair failure/revision, amputation, or in-hospital mortality. RESULTS: Among 165 patients, the median age was 34 years, 149 (90%) were male, and 99 (60%) suffered penetrating injury. Popliteal (46%) and superficial femoral (44%) arterial injuries were most common. Interposition graft/bypass was the most frequent repair (n = 107 [65%]). Revascularization failure was observed in 24 patients (15%). Compared with trauma surgeons, vascular surgeons more frequently repaired blunt injuries (66% vs. 20%, p < 0.001), anterior tibial (18% vs. 5%, p = 0.012), or tibioperoneal injuries (28% vs. 4%, p < 0.001), with a below-knee bypass (38% vs. 20%, p = 0.019). Revascularization failure occurred in 10% (9 of 93) of repairs by trauma surgeons and 21% (13 of 61) of repairs by vascular surgeons. Mangled Extremity Severity Score >8 (odds ratio, 15.6; 95% confidence interval, 4.4-55.9; p < 0.001) and concomitant laparotomy or orthopedic procedure (odds ratio, 6.7; 95% confidence interval, 1.6-28.6; p = 0.010) were independently associated with revascularization failure. A novel composite scoring system (UT Houston Score) was developed by combining Mangled Extremity Severity Score, concomitant procedure, mechanism of injury, and injury location. This score demonstrated a sensitivity of 100% with a score of 0 and a specificity of 95% with a score of >3. CONCLUSION: After traumatic arterial injury, trauma surgeons repaired less-complex injuries but with fewer revascularization failures than vascular surgeons. The UT Houston Score may be used to risk stratify patients to determine who may benefit from vascular surgery consultation. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Peripheral vascular trauma - basic management, diagnosis and treatment.

INTRODUCTION: Peripheral vascular injuries occur in 1-3% of all traumas in civilian settings. The management of these injuries is often based on experience derived from war medicine where these injuries are more common. The goal of this article is to summarize basic guidelines for the diagnosis and treatment of vascular injuries. METHODS: Western Trauma Association (WTA) and Eastern Association for the Surgery of Trauma (EAST) both have their own guidelines for vascular trauma management. RESULTS: Vascular injuries occur both in penetrating and blunt traumas. Complete vessel disruption occurs more frequently in penetrating traumas. In the case of blunt trauma, intimal defects are more common, resulting in dissection, false aneurysm, or intramural hematoma. The limb is mostly endangered due to ischemia, reperfusion injury and the compartment syndrome. Prompt diagnosis and treatment are paramount. Vascular trauma management is part of the ATLS protocol and life-over-limb principle. The primary goal is to stop the massive external bleeding. Clinical examination and CT angiography are the most helpful for the diagnosis. Surgical revision is indicated when hard signs are present. This can be a damage control surgery with the primary goal to stop the bleeding as quickly as possible. A shunt can be used for temporary reperfusion of the limb. Definitive treatment can take the form of a simple suture, patches or graft interposition; both prosthetic and autologous grafts are used. Sufficient debridement and fasciotomy are important steps in the therapy. In some cases, endovascular treatment can be used. CONCLUSION: Over the last century, the treatment strategy changed dramatically. Data from recent military conflicts show a decrease in amputation rates, and limb salvage has become a standard.

Lumbar Artery Injury Related to Percutaneous Pedicle Screw Insertion.

A 75-year-old woman underwent L4-L5 lateral interbody fusion for L4-5 foraminal stenosis with the use of percutaneous pedicle screws. On the day after the surgery, she was in shock. Emergency contrast-enhanced CT showed active extravasation from the 4th lumbar artery with a transverse process fracture. A radiologist performed a successful transarterial embolization, and the patient then began walking training on the 4th day post-surgery. Close attention should be paid to the insertion of a percutaneous pedicle screw, as it may cause a lumbar artery injury; in such a case, transarterial embolization is the preferred treatment.

Timing is everything: Impact of combined long bone fracture and major arterial injury on outcomes.

BACKGROUND: Timing of extremity fracture fixation in patients with an associated major vascular injury remains controversial. Some favor temporary fracture fixation before definitive vascular repair to limit potential graft complications. Others advocate immediate revascularization to minimize ischemic time. The purpose of this study was to evaluate the timing of fracture fixation on outcomes in patients with concomitant long bone fracture and major arterial injury. METHODS: Patients with a combined long bone fracture and major arterial injury in the same extremity requiring operative repair over 11 years were identified and stratified by timing of fracture fixation. Vascular-related morbidity (rhabdomyolysis, acute kidney injury, graft failure, extremity amputation) and mortality were compared between patients who underwent fracture fixation prerevascularization (PRE) or postrevascularization (POST). RESULTS: One hundred four patients were identified: 19 PRE and 85 POST. Both groups were similar with respect to age, sex, Injury Severity Score, admission base excess, 24-hour packed red blood cells, and concomitant venous injury. The PRE group had fewer penetrating injuries (32% vs. 60%, p = 0.024) and a longer time to revascularization (9.5 vs. 5.8 hours, p = 0.0002). Although there was no difference in mortality (0% vs. 2%, p > 0.99), there were more vascular-related complications in the PRE group (58% vs. 32%, p = 0.03): specifically, rhabdomyolysis (42% vs. 19%, p = 0.029), graft failure (26% vs. 8%, p = 0.026), and extremity amputation (37% vs. 13%, p = 0.013). Multivariable logistic regression identified fracture fixation PRE as the only independent predictor of graft failure (odds ratio, 3.98; 95% confidence interval, 1.11-14.33; p = 0.03) and extremity amputation (odds ratio, 3.924; 95% confidence interval, 1.272-12.111; p = 0.017). CONCLUSION: Fracture fixation before revascularization contributes to increased vascular-related morbidity and was consistently identified as the only modifiable risk factor for both graft failure and extremity amputation in patients with a combined long bone fracture and major arterial injury. For these patients, delaying temporary or definitive fracture fixation until POST should be the preferred approach. LEVEL OF EVIDENCE: Prognostic study, Level IV.

In-hospital outcomes in autogenous vein versus synthetic graft interposition for traumatic arterial injury: A propensity-matched cohort from PROOVIT.

BACKGROUND: The ideal conduit for traumatic arterial repair is controversial. Autologous vein was compared with synthetic interposition grafts in the acute setting. The primary outcome was in-hospital reoperation or endovascular intervention. METHODS: The American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment registry from November 2013 to January 2019 was queried for arterial injuries requiring interposition vein or graft repair. Patients with no recorded Injury Severity Score were excluded, and multiple imputation was used for other missing data. Patients treated with synthetic grafts (SGs) were propensity matched to patients with vein grafts (VGs) to account for preoperative differences. RESULTS: Four hundred sixty from 19 institutions were identified, with 402 undergoing VG and 58 SG. In the SG group, 45 were PTFE grafts, 5 were Dacron, and 8 had other conduits. The SG group was more severely injured at admission with more gunshot wounds and higher mean Injury Severity Score, lactate, and first-24-hour transfusion requirement. In addition, the SG cohort had significantly lower admission systolic blood pressure, pH, and hemoglobin. After propensity matching, 51 patients with SG were matched with 87 patients with VG. There were no differences in demographics, clinical parameters, or diagnostic evaluation techniques postmatch. The need for reoperation or endovascular intervention between the matched groups was equivalent (18%; p = 0.8). There was no difference in any secondary outcome including thrombosis, stenosis, pseudoaneurysm, infection, or embolic event, and hospital and intensive care unit length of stay were the same. CONCLUSION: American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment registry data demonstrate that SGs are used in more critically ill patients. After controlling for relevant clinical factors and propensity matching, there is no in-hospital difference in rate of reoperation or endovascular intervention, or any secondary outcome between VG and SG. LEVEL OF EVIDENCE: Prognostic and Epidemiolgic, Level III.

Factores asociados al síndrome de Wellens en pacientes con síndrome coronario agudo sin elevación del segmento ST / Factors associated to Wellens' syndrome in patients with acute coronary syndrome without ST-segment elevation

Introducción: El síndrome de Wellens constituye un equivalente del síndrome coronario agudo con elevación del segmento ST. Este incluye dos patrones electrocardiográficos que sugieren lesión crítica de la arteria descendente anterior. Objetivo: Evaluar probables factores asociados al síndrome de Wellens en pacientes con síndrome coronario agudo sin elevación del segmento ST y lesiones coronarias significativas en la arteria descendente anterior. Material y métodos: Se realizó un estudio observacional, analítico, transversal en pacientes con diagnóstico de síndrome coronario agudo sin elevación del ST y lesión significativa en la arteria descendente anterior, comprobada mediante coronariografía, ingresados en la unidad de cuidados coronarios intensivos del Hospital Clínico-Quirúrgico Manuel Fajardo entre el 2016 y 2019. Resultados: La edad media fue de 66 años, predominó el sexo masculino (53,9 por ciento) y el antecedente de hipertensión arterial (89,5 por ciento). Los pacientes con síndrome de Wellens tuvieron un significativo menor porcentaje de antecedente de cardiopatía isquémica (58,1 por ciento vs. 84,8 por ciento; p = 0,012). Además, el síndrome arrojó asociación estadísticamente muy significativa con la condición de fumador activo (51,2 por ciento vs. 15,2 por ciento; p < 0,01). No se encontró relación estadística significativa entre el síndrome de Wellens y el resultado angiográfico. Conclusiones: La presencia de los patrones electrocardiográficos del síndrome de Wellens se asocia con el hábito tabáquico en pacientes con síndrome coronario agudo sin elevación del segmento ST y lesiones coronarias en la arteria descendente anterior, y su ausencia se asocia con el antecedente de cardiopatía isquémica en el mismo subgrupo de individuos(AU)

Introduction: Wellens' syndrome is equivalent to acute coronary syndrome with ST-segment elevation. It includes two electrocardiographic patterns suggesting a critical lesion in the anterior descending artery. Objective: Evaluate probable factors associated to Wellens' syndrome in patients with acute coronary syndrome without ST-segment elevation and significant coronary lesions in the anterior descending artery. Methods: A cross-sectional observational analytical study was conducted of patients diagnosed with acute coronary syndrome without ST-segment elevation and significant lesion in the anterior descending artery verified by coronary arteriography, admitted to the intensive coronary care unit at Manuel Fajardo Clinical Surgical Hospital in the period 2016-2019. Results: Mean age was 66 years, with a predominance of the male sex (53.9 percent) and a history of hypertension (89.5 percent). Patients with Wellens' syndrome had a significantly lower percentage of ischemic heart disease antecedents (58.1 percent vs. 84.8 percent; p = 0.012). A very significant statistical association was observed between the syndrome and active smoking (51.2 percent vs. 15.2 percent; p < 0.01). A significant statistical relationship was not found between Wellens' syndrome and angiographic results. Conclusions: The presence of electrocardiographic patterns of Wellens' syndrome is associated to smoking in patients with acute coronary syndrome without ST-segment elevation and coronary lesions in the anterior descending artery, whereas their absence is associated to a history of ischemic heart disease in the same subgroup of individuals(AU)

Terapia endovascular en trauma periférico: una alternativa a la cirugía abierta tradicional / Endovascular therapy in peripheral trauma: our experience

Resumen Introducción: La terapia endovascular ha demostrado ser una buena alternativa de tratamiento en las enfermedades arteriales y venosas. Asimismo, en trauma vascular periférico constituye una excelente opción, especialmente en sitios anatómicos difíciles de acceder y con lesiones complejas como seudoaneurismas, fístulas arteriovenosas (FAV) o la combinación de ambos, con numerosas ventajas. Objetivo: Evaluar los resultados del tratamiento endovascular en trauma vascular penetrante por agresiones y iatrogenias. Materiales y Método: Revisión retrospectiva de todos los pacientes con trauma vascular periférico sometidos a terapia endovascular. Resultados: Entre abril de 2011 y mayo de 2020 se trataron 30 pacientes, 28 hombres y 2 mujeres. Con edades fluctuantes entre 17 y 84 años. La causa del trauma fue 20 penetrantes y 10 iatrogenias. Los vasos afectados fueron arteria femoral superficial 6, femoral profunda 2, subclavia 9, axilar 1, poplítea 4, ilíacas 1, peronea 1, tibial anterior 5, tronco venoso braquiocefálico 1. Diecisiete pacientes fueron tratados con endoprótesis, 9 con embolización y 4 con cierre percutáneo en relación con catéteres arteriales en subclavia. No hubo mortalidad, pero dos pacientes requirieron reparación abierta: un seudoaneurisma poplíteo gigante y un seudoaneurisma de tibial anterior, en ambos se constató sección completa de ambas arterias. El seguimiento clínico ha sido entre 30 días y 3 años. Conclusiones: En esta serie de casos, la terapia endovascular en lesiones de trauma vascular periférico ofrece excelentes resultados con baja morbimortalidad y permeabilidad aceptable a corto y mediano plazo.

Introduction: Endovascular therapy has proven to be a good treatment alternative in arterial and venous diseases. Likewise, in peripheral vascular trauma it is an excellent option, especially in anatomical sites that are difficult to access and with complex lesions such as pseudoaneurysms, arteriovenous fistulas (AVFs) or the combination of both, with numerous advantages. Aim: To evaluate the results of endovascular treatment in trauma Penetrating vascular injury and iatrogenesis. Materials and Method: Retrospective review of all patients with peripheral vascular trauma undergoing endovascular therapy. Results: Between April 2011 and May 2020, 30 patients were treated, 28 men and 2 women. With fluctuating ages between 17 and 84 years. The cause of the trauma was 20 penetrating and 10 iatrogenic. The affected vessels were superficial femoral artery 6, deep femoral 2, subclavian 9, axillary 1, popliteal 4, iliac 1, peroneal 1, anterior tibial 5, brachiocephalic venous trunk 1. Seventeen patients were treated with endoprosthesis, 9 with embolization and 4 with percutaneous closure in relation to arterial catheters in the subclavian. There was no mortality but two patients required open repair: a giant popliteal pseudoaneurysm and an anterior tibial pseudoaneurysm in which both sections of both arteries were found to be complete. Clinical follow-up was between 30 days and 3 years. Conclusión: In this serie, endovascular therapy in peripheral vascular trauma lesions offers excellent results with low morbidity and mortality and acceptable patency in the short and medium term.

Posterior Wall Acetabulum Fracture with a Persistent Sciatic Artery: A Case Report.

CASE: We report the case of a patient who sustained a left posterior wall acetabular fracture with an ipsilateral persistent sciatic artery (PSA). The PSA was diagnosed preoperatively on lower extremity computed tomography angiogram. He was treated with open reduction internal fixation through a Kocher-Langenbeck approach. The PSA and sciatic nerve were identified and protected throughout the case. There were no neurovascular complications. CONCLUSION: PSA in the setting of posterior wall acetabulum fractures has not been reported previously. Orthopaedic surgeons who treat these injuries should be aware of PSA anatomic variants so that they can be identified and protected during surgery.

Three-Dimensional Computed Tomography of the Detoured Facial Artery: Variations and Implications for Nasojugal Groove Correction.

BACKGROUND: When performing filler injection procedures to the nasojugal groove, there is the risk of iatrogenic damage to the detoured facial artery. OBJECTIVE: To determine the 3-dimensional location of the detoured facial artery. MATERIALS AND METHODS: The branches of the facial arteries from 118 cadaveric hemifaces were scanned using computed tomography and reconstructed using the Mimics software program. RESULTS: Detoured facial arteries were found in 47 of the 118 hemifaces (39.8%). Two main arterial patterns were identified: in Type I (29 of 47 cases), there were both detoured and nasolabial trunks where the facial artery originated, whereas in Type II (18 of 47 cases), there was only a detoured trunk. The detoured trunk originated 32.0 ± 5.3 mm from the midsagittal line, 5.0 ± 2.8 mm from the occlusion plane, and 5.9 ± 3.5 mm below the skin layer; the inflection of the detoured trunk was located 30.0 ± 5.6 mm laterally, 26.2 ± 4.4 mm superiorly, and 5.7 ± 2.6 mm deep. The meeting point with the inferior orbital rim plane was located 17.1 ± 3.4 mm laterally, 43.4 ± 3.1 mm superiorly, and 2.8 ± 1.7 mm deep. CONCLUSION: The 3-dimensional location of the detoured facial artery as reported here will help clinicians to avoid iatrogenic damage when they are performing filler injection procedures.

Outcomes of Arterial Grafts for the Reconstruction of Military Lower Extremity Arterial Injuries.

INTRODUCTION: Lower extremity (LE) arterial injuries are common in military casualties and limb salvage is a primary goal. Bypass grafts are the most common reconstructions; however, their specific outcomes are largely unreported. We sought to describe the outcomes of LE arterial grafts among combat casualties and their association with limb loss. METHODS: Retrospective cohort study of 2004-2012 Iraq/Afghanistan casualties with LE arterial injury undergoing bypass graft from a database containing follow-up until amputation, death, or military discharge. Primary outcome was composite graft complications (GC-thrombosis, stenosis, pseudoaneurysm, blowout, and/or arteriovenous fistula). RESULTS: Two hundred and twenty-two grafts were included (99 femoral, 73 popliteal, 48 tibial). 56 (26%) had at least one GC; thrombosis was most common in femoral, stenosis most common in popliteal and tibial. GC was not associated with graft level but was associated with synthetic conduit (P = 0.01) and trended towards an association with multiple-level arterial injuries (P = 0.07). Four of eight (50%) synthetic grafts had amputations, all within 72h. Two of the eight synthetic grafts thrombosed, and both limbs were amputated. There were 52 total amputations. Amputation was performed in 13 (23%) of limbs with a GC and 24% of those without (P = 0.93) Overall, 24 (11%) of grafts thrombosed, 16 within 48h and 13 (25%) in limbs undergoing amputation (P = 0.001 for association of thrombosis with amputation). CONCLUSION: GC are common among LE bypass grafts in combat casualties but are not associated with limb loss. Thrombosis is predominantly early and is associated with amputation. Closer attention to ensuring early patency may improve limb salvage.

Management of Inadvertent Supra-aortic Arterial Lesions During Central Venous Access Procedures: Report of Six Cases and Proposed Algorithm.

Accidental supra-aortic arterial cannulation during central venous catheter (CVC) insertion is a rare and serious complication associated with risk of vascular and neurologic complications. The aim of this study is describing our 6 cases experience and propose a management algorithm. We retrospectively evaluated the diagnosis and treatment of six patients arrived at our Department for accidental supra-aortic arterial cannulation during CVC insertion. They underwent Doppler Ultrasonography (DUS) or Computed Tomography Angiography (CTA) to confirm the arterial damage and to decide the correct therapeutic pathway. Four patients underwent DUS as the shallow location of injured arteries and 2 patients CTA because of the arterial damage deeply located. Surgical procedure with direct arterial suture was performed in four patients. Endovascular treatment with stent graft deployment was carried out in two patients. All procedures were conducted successfully: technical success (immediate hemostasis and vessel patency) was obtained in 100% of the cases. Postoperative imaging (DUS or CTA) confirmed the absence of arterial bleeding and the arterial patency. No perioperative mortality or complications occurred. After a careful review of literature and our case series, we proposed an algorithm to delineate the optimal treatment strategy, explaining that early and careful diagnosis (by DUS or CTA) and prompt repair appear crucial to achieve good outcomes and clarifying that an endovascular technique (stent graft placement or vascular closure device) seems to be the best treatment in these cases. Finally, an open surgical technique could be indicated in case of common carotid artery injury and concurrent catheter passing through the target vein.

An Anatomical Guide to the Terminal Facial Artery: Lumen Diameter and Associated Anatomy Relevant to Dermatologic Procedures.

BACKGROUND: Dermal filler injection in the vicinity of the terminal facial artery (FA) can lead to vascular compromise with devastating consequences, including tissue necrosis, blindness, and stroke. OBJECTIVE: The purpose of this study was to examine lumen diameter and other anatomical features of the terminal FA relevant to dermal filler injection. MATERIALS AND METHODS: Eighteen embalmed adult cadavers were dissected along the distribution of the terminal FA. Gross and microscopic measurements were taken at predetermined points in its course. RESULTS: Mean lumen diameter was largest at the midpoint between the oral commissure and the lateral supra-alar crease (0.81 ± 0.36 mm; point P1) and smallest at the midpoint between the lateral supra-alar crease and the medial canthus (0.43 ± 0.23 mm; point P3). Mean cutaneous depth was deepest at the lateral supra-alar crease (5.06 ± 1.84 mm; point P2) and most superficial at the midpoint between the lateral supra-alar crease and the medial canthus (3.13 ± 2.07 mm; point P3). CONCLUSION: The large-caliber lumen diameter of the terminal FA creates the potential for intra-arterial injection with commonly used filler needles and blunt-tipped cannulas at all points in its course in the nasolabial fold and midface.

Open vs Endovascular Treatment of Traumatic Peripheral Arterial Injury: Propensity Matched Analysis.

BACKGROUND: Arterial injuries occur in the setting of blunt and penetrating trauma. Despite increasing use, there remains a paucity of data comparing long-term outcomes of endovascular vs open repair management of these injuries. The aim of our study was to compare outcomes and readmission rates of open vs endovascular repair of traumatic arterial injuries. STUDY DESIGN: The National Readmission Database (2011-2014) was queried for all adult (age ≥ 18 y) patients presenting with peripheral arterial (axillary, brachial, femoral, and popliteal) injuries. Patients were stratified into 2 groups based on intervention: open vs endovascular approach. Propensity score matching (1:2 ratio) was performed. Outcomes measures were complications, length of stay (LOS), 30-day readmission, and cost of readmission. RESULTS: A matched cohort of 786 patients was obtained (endovascular: 262, open: 524). Mean age was 45 ± 17 years, and 79% were males. Median LOS was 4 (range 2-6) days for the endovascular group vs 3 (range 2-5) days for the open group (p < 0.01). The endovascular group had higher rates of seroma (4% vs 2%; p = 0.04) and arterial thrombosis (13% vs 7%; p < 0.01) during index hospitalization. Patients who underwent endovascular repair had higher 30-day readmission (11% vs 7%; p = 0.03) and a higher 30-day open-reoperation rate (6% vs 2%; p < 0.01). On subanalysis of the patients who were readmitted, the median cost of each readmission was higher in the endovascular group $47,000 ($27,202-$56,763) compared with $21,000 ($11,889-$43,503) in the open group. CONCLUSIONS: Endovascular repair for peripheral arterial injuries was associated with higher rates of in-hospital complications, readmissions, and costs. As this new technology continues to undergo refinement, a thorough re-evaluation of its indications, risks, and benefits is warranted.

Traumatic Arterio-Enteric Fistula-A Report of 2 Cases With Review of Literature.

BACKGROUND: Traumatic arterio-enteric fistula is predominantly seen after penetrating trauma with only 21 reported cases documented in the past 25 years. They may present in an acute or delayed manner with upper or lower gastrointestinal bleed. A detailed clinical examination with requisite imaging can help in detecting such injuries. CASE DESCRIPTION: Case 1: A 20-year-old gentleman, presented with penetrating stab injury to the gluteal region with bleeding per rectum. Imaging revealed evidence of injury to the inferior rectal artery which was found to be communicating with the extraperitoneal portion of the rectum. He was managed with a combination of endovascular and open surgery with a successful outcome. Case 2: A 29-year-old gentleman, presented in a delayed manner 2 weeks after a gunshot wound to the gluteal region, which was managed operatively in another hospital. He developed a massive lower gastrointestinal bleed 2 weeks after presentation. Imaging revealed evidence of a pseudoaneurysm of the inferior gluteal artery which had a fistulous communication with the gastrointestinal tract leading to bleeding. It was managed by endovascular techniques successfully. CONCLUSION: Arterio-enteric fistulas following trauma are rare phenomena and they need a high index of suspicion for diagnosis. Once diagnosed, they can be managed based on their location and patient physiology by interventional techniques, surgery, or a combination of the two.

Outcome Predictors in Civilian and Iatrogenic Arterial Trauma.

BACKGROUND: Our aim was to identify predictors of mortality and limb loss in iatrogenic and civilian arterial trauma. METHODS: Cases were identified by searching prospectively maintained registries. Multivariable logistic regression was used to identify independent outcome predictors. RESULTS: During the study period, 285 patients with arterial trauma were managed with endovascular (n = 20) or open (n = 265) repair. Iatrogenic injuries increased in frequency during the course of the study, from 23.9% during the first decade to 35.9 and 55.7% during the second and third decade, respectively (p < 0.001). Endovascular management increased in frequency during the course of the study, from 0% during the first decade to 5.1 and 11.1% during the second and third decade, respectively (p = 0.005). Mortality was 9.8%, and limb loss (in cases with injury of the aorta or limb arteries, n = 259) was 6.2%. Independent predictors of mortality included increased age (odds ratio, 95% confidence interval [OR, 95% CI] 1.05 (1.02-1.07), p < 0.001), blunt trauma (OR [95% CI] 4.8 (1.9-12.2), p = 0.001) and the number of RBC units transfused intraoperatively (OR [95% CI] 1.25 (1.1-1.4), p = 0.001). Independent predictors of limb loss included the first half of the study period (OR [95% CI] 3.9 (1.1-14.1), p = 0.04), lower extremity arterial trauma (vs upper extremity, aortic, common or external iliac artery trauma, OR [95% CI] 8.3 (1.9-35.7), p = 0.004), bone fracture (OR [95% CI] 16.9 (4.7-62.5), p < 0.001) and the number of RBC units transfused intraoperatively (OR [95% CI] 1.16 (1.02-1.33), p = 0.024). CONCLUSION: Increasingly iatrogenic in cause and managed by endovascular methods, arterial trauma remains a problem associated with significant mortality and limb loss. Identification of unfavourable outcome predictors may help clinicians involved with arterial trauma to escalate the level of care.

Utility of the Mangled Extremity Severity Score in Predicting Amputation in Military Lower Extremity Arterial Injury.

BACKGROUND: Effective amputation prediction may help inform appropriate early limb salvage efforts in military lower extremity (LE) arterial injury. The Mangled Extremity Severity Score (MESS) is the most commonly applied system for early amputation prediction but its utility in military trauma is unknown. METHODS: Retrospective cohort study of Iraq and Afghanistan casualties with LE arterial injury who underwent a vascular limb salvage attempt. Retrospectively assessed MESS was statistically explored as an amputation predictor and MESS component surrogates (mechanism, vascular injury characteristics, tourniquet use, and transfusion volume) were used to characterize limb injuries by presenting characteristics and evaluated for amputation prediction. RESULTS: A total of 439 limbs were included with 99 (23%) amputations, 29 (7%) within 48 hr of injury. Median MESS was 5 (interquartile range 4-6) among salvaged limbs and 7 (5-9) among amputations (P < 0.0001). An MESS cutoff of ≥7 had a better receiver operating characteristic sensitivity/specificity profile (area under the curve 0.696 overall, 0.765 amputation within 48 hr) than MESS ≥8 (0.593, 0.621), but amputation rates were only 43% for MESS ≥7 and 50% for ≥8. MESS ≥7 was significantly associated with age, polytrauma, blast or crush mechanism, fracture, tourniquet use, distal (popliteal/tibial) and multiple arterial injuries, and massive transfusion. Amputation was significantly associated with polytrauma, blast or crush mechanism, fracture, and massive transfusion; however, 83 casualties had all 4 characteristics with an amputation rate of only 46%. CONCLUSIONS: In combat casualties with arterial injury, LE amputation after attempted vascular limb salvage is inadequately predicted by existing scoring systems or the presenting characteristics available in this registry. Limb loss is predominantly late and likely because of factors not projectable at initial presentation.