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.

The cost of gunshot abdominal vascular injuries. Its impact on patient, family and hospital.

BACKGROUND: Violent trauma with penetrating injuries is a relevant public health issue. Penetrating abdominal wounds cause 90-95% of vascular injuries, which not only have high associated morbidity and lethality, but also involve high attention costs. Cost analysis in hospitals has become a topic of great interest, as it justifies changes in hospital organization and management. OBJECTIVE: Determine the cost of gunshot abdominal vascular injuries for the patient, his family and the hospital. MATERIAL AND METHODS: We drove an observational, descriptive, prospective and longitudinal study of patients with of gunshot abdominal vascular injuries admitted in the Mexican Red Cross Trauma Center in the Federal District from January 1st to October 31st, 2018. RESULTS: 8149 patients were admitted in the emergency department, 149 with a diagnosis of gunshot injury, of which 6 (0.07%) had abdominal vascular injury. The total cost of medical care these patients was on average $174,770.79 (median $132,999.50) per capita, amount that surpasses their annual income and implies an institutional absorption of expenditure up to 95.5%. CONCLUSIONS: Institutional investment on the attention of high-impact pathologies and the development of strategies that facilitate access to health services are a real and priority necessity.

ANTECEDENTES: El trauma violento con lesiones penetrantes es un problema de salud pública relevante. Las heridas penetrantes abdominales causan el 90-95% de las lesiones vasculares, las cuales tienen elevada morbilidad asociada y letalidad, e implican elevados costos de atención. El análisis de costos en los hospitales es de gran interés, pues permite justificar cambios en la organización y la gestión hospitalaria. OBJETIVO: Determinar el costo de las lesiones vasculares abdominales por proyectil de arma de fuego para el paciente, su familia y el hospital. MATERIAL Y MÉTODOS: Se llevó a cabo un estudio observacional, descriptivo, prospectivo y longitudinal de pacientes con lesiones vasculares abdominales por proyectil de arma de fuego que ingresaron en el Centro de Trauma de Cruz Roja Mexicana en Ciudad de México entre enero y octubre de 2018. RESULTADOS: Ingresaron 8149 pacientes, 149 con diagnóstico de herida por proyectil de arma de fuego, de los cuales el 0.07% tuvieron lesión vascular abdominal. El costo total de la atención médica fue en promedio de $174,770.79 (mediana $132,999.50) por persona, el cual supera el ingreso anual de esos pacientes e implica una absorción institucional del gasto de hasta el 95.5%. CONCLUSIONES: La inversión institucional en la atención de patologías con alto impacto y el desarrollo de estrategias para facilitar el acceso a servicios de salud son una necesidad prioritaria real.

The national incidence of iatrogenic popliteal artery injury during total knee replacement.

INTRODUCTION: The aim of this study was to characterize national characteristics of patients who have a total knee replacement complicated by popliteal artery injury by incidence and patient demographics. METHODS: All patients with ICD-9 confirmed total knee replacement who had an iatrogenic popliteal artery injury were included from the national in-patient sample from 1998 to 2011. Age, gender and race, procedure type, time to popliteal artery injury, limb outcome, length of stay and hospital inpatient charges were reported. RESULTS: A total of 1,297,369 patients underwent a total knee replacement of which 43 were complicated by popliteal artery injury (0.003%); 93% had osteoarthritis as their primary diagnosis. The mean age was 61.7 ± 12.3 years. In all, 96% of patients had their popliteal injuries detected intra-operatively or on the day of total knee replacement surgery. The majority of these patients either received stent placement (44%) or peripheral bypass (30%) as their treatment modality for popliteal artery injury. There were no amputations or deaths in this cohort. The median hospital charges for this group were $27,570 (2014 USD). CONCLUSION: The national incidence of iatrogenic popliteal artery injury in patients undergoing TKR is 0.003%. There were no amputations in our study population and 96% of patients had their injury detected intra-operative or immediately post-operatively.

Popliteal artery injury associated with total knee arthroplasty: trends, costs and risk factors.

Popliteal artery injury is a relatively rare but potentially devastating complication of total knee arthroplasty (TKA). We analyzed the Nationwide Inpatient Sample from 1998 to 2009 to determine the actual incidence, risk factors and consequences of this complication. There were 1,120,508 hospitalizations coded for TKA; of these, 633 (0.057%) were identified as having a popliteal artery injury. The rate of injury remained relatively constant though the number of both TKAs and injuries have risen annually by 0.65% and 0.5%, respectively. Significant risk factors included revision surgery, peripheral vascular disease, weight loss, renal failure, coagulopathy, and metastatic cancer. Consequences were increased hospital charges, length of stay, and mortality rates. Because the rate of popliteal artery injury is not diminishing with time and morbidity and mortality are high, patients should be assessed for known risk factors for popliteal artery injury.

An outcome analysis of endovascular versus open repair of blunt traumatic aortic injuries.

BACKGROUND: Aortic injury is the second most common cause of death after blunt trauma. Thoracic endovascular aortic repair (TEVAR) has been rapidly adopted as an alternative to the traditional open repair (OR) for treatment of traumatic aortic injury (TAI). This paradigm shift has improved the outcomes in these patients. This study evaluated the outcomes of TEVAR compared with OR for patients with TAI. METHODS: We analyzed prospectively collected data from the institutional trauma registry between April 2002 and June 2010. These data were supplemented with a retrospective review of hospital financial accounts. The primary outcome was the presence or absence of any complication, including in-hospital death. Secondary outcomes included fixed, variable, and total hospital costs and intensive care unit (ICU), preoperative, postoperative and total hospital length of stay (LOS). RESULTS: Amongst 106 consecutive patients (74 men; mean age, 36.4 years), 56 underwent OR and 50 underwent TEVAR for treatment of TAI. The proportion of patients who underwent TEVAR compared with OR increased from 0% to 100% during the study period. The TEVAR patients were significantly older than the OR patients (41.1 vs 32.2 years, P=.012). For patients who underwent TEVAR, the estimated odds ratio (95% confidence interval) of complications, including in-hospital mortality was 0.33 (0.11-0.97; P=.045) compared with the OR group. The average number of complications, including in-hospital death, was higher in the OR group than in the TEVAR group (adjusted means, 1.29 vs 0.94). The OR group had a higher proportion of patients with complications, including in-hospital death, compared with the TEVAR group (69.6% vs 48%). Although, the mean adjusted variable costs were higher for TEVAR than for OR (P=.017), the mean adjusted fixed and total costs were not significantly different. Owing to a policy of delayed selective management, the adjusted preoperative LOS was significantly higher for TEVAR (9.8 vs 3.0 days, P=.022). The difference in the ICU or total hospital LOS was not significant. Although the proportion of uninsured patients was similar in both groups, the cohort (n=106) had a significantly higher proportion of uninsured patients (29% vs 5%) compared with the general vascular surgical population at our institution (0.29 vs 0.051, 95% confidence interval for difference in proportions, 0.22-0.40; P<.0001). CONCLUSIONS: Compared with TEVAR, patients who underwent OR had three times higher odds to face a complication or in-hospital death. The mean total cost of TEVAR was not significantly different than OR. The findings support the use of TEVAR over OR for patients with TAI.