Pediatric cerebrovascular trauma: Incidence, management, and outcomes.

BACKGROUND: Pediatric cerebrovascular trauma (CVT) is rare. There is an increasing use of endovascular management in vascular trauma. We studied the incidence, management, and outcomes of CVT in the pediatric population using the NTDB (National Trauma Data Bank). METHODS: The NTDB was queried for CVT in patients less than 18 years of age over a recent three-year period (2017-2019). Demographics, injury mechanism, type and location, Glasgow Coma Score (GCS), length of stay (LOS), surgical approach (open vs endovascular), and morbidity/mortality were evaluated. Statistical analysis included χ2 and student's t-tests or Fisher's exact tests where appropriate. RESULTS: Of 386,918 pediatric trauma cases, 1536 (0.4%) suffered 1821 CVT. Blunt trauma accounted for 69.3%. Patients were predominantly male (65.4%) and white (57.5%), with an mean age of 14 years. There were 998 (55%) carotid artery injuries, including 846 common/internal carotid and 145 external carotid. Other vessel injuries included 141 (11%) intracranial carotid, 571 (31%) vertebral artery and 252 (14%) jugular vein. Mean number of vessels injured was 1.2. Motor vehicle trauma was most common (49.3%) followed by firearm injury (21%). The mean GCS was 11, and mean total LOS was 11.3 days. Majority of interventions were performed in an open fashion (65.7%), whereas 29.7% were performed endovascularly. Stroke rate was 3.1%. Patients with multiple vascular injuries had an overall mortality of 29% (p<0.0001). CONCLUSION: While not accorded as much importance as blunt injury, penetrating CVT comprises of 30% of injuries. Nearly 1/3rd of all cases needing surgical intervention were managed with endovascular techniques. LEVEL OF EVIDENCE: III.

Area Deprivation Index Score is Associated with Lower Rates of Long Term Follow-up after Upper Extremity Vascular Injuries.

The Area Deprivation Index (ADI) has been shown to be a determinant of healthcare outcomes in both medical and surgical fields, and is a measure of the socioeconomic status of patients. We sought to analyze outcomes in patients with upper extremity vascular injuries that were admitted over a five-year period to a Level I trauma center sorted by ADI. All patients with upper extremity vascular injury presenting to a level one trauma center between January 2013 and January 2017 were retrospectively collected. The patients were divided into two groups based on their ADI with the first group representing the lowest quartile of patients and the second group the higher three quartiles. Patient's demographics were analyzed as well as modes of trauma, hospital transfer status prior to receiving care, type of intervention received, follow-up rates and outcomes including both complication and amputation rates. Over this time period, a total of 88 patients with traumatic upper extremity vascular injuries were identified. The majority of injuries were due to penetrating trauma (74/88, 84%) with 41% (10/24) of patients in the lower ADI being victims of gunshot wounds compared to 27% (17/64) of those in the higher ADI (P = 0.19). Patients in the lowest ADI quartile were more likely to be African Americans (P= 0.0001), and more likely to be transferred to our university hospital prior to receiving care (P= 0.007). Arrival Glasgow Coma Scale and Injury Severity Score were similar as was time spent in the emergency room. Length of stay trended longer in the lowest ADI quartile as compared to the higher ADI (7.5 vs. 11.8, P= 0.59). The rates of long term follow-up were significantly lower in patients with the lowest ADI scores as opposed to the higher ADI group (P= 0.0098), however, there was no statistically significant difference in outcomes between the two groups including both complication and amputation rates. The ADI is associated with lower rates of long term follow-up after upper extremity vascular injuries, despite patients in both the high and low ADI groups having similar outcomes in regards to complication and amputation rates. Further study is warranted to investigate the role of the socioeconomic status in outcomes following traumatic injury.

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.

Incidence, Management, Immediate and Long-Term Outcome of Guidewire and Device Related Grade III Coronary Perforations (from G3CAP - Cardiogroup VI Registry).

Ellis grade III coronary artery perforations (G3-CAP) remain a life-threatening complication of percutaneous coronary intervention (PCI), with high morbidity and mortality and lack of consensus regarding optimal treatment strategies. We reviewed all PCIs performed in 10 European centers from 1993 to 2019 recording all G3-CAP along with management strategies, in-hospital and long-term outcome according to Device-related perforations (DP) and Guidewire-related perforations (WP). Among 106,592 PCI (including 7,773 chronic total occlusions), G3-CAP occurred in 311 patients (0.29%). DP occurred in 194 cases (62.4%), more commonly in proximal segments (73.2%) and frequently secondary to balloon dilatation (66.0%). WP arose in 117 patients (37.6%) with chronic total occlusions guidewires involved in 61.3% of cases. Overall sealing success rate was 90.7% and usually required multiple maneuvers (80.4%). The most commonly adopted strategies to obtain hemostasis were prolonged balloon inflation (73.2%) with covered stent implantation (64.4%) in the DP group, and prolonged balloon inflation (53.8%) with coil embolization (41%) in the WP group.  Procedural or in-hospital events arose in 38.2% of cases: mortality was higher after DP (7.2% vs 2.6%, p = 0.05) and acute stent thrombosis 3-fold higher (3.1% vs 0.9%, p = 0.19). At clinical follow-up, median 2 years, a major cardiovascular event occurred in one-third of cases (all-cause mortality 8.2% and 7.1% respectively, without differences between groups). In conclusion, although rare and despite improved rates of adequate perforation sealing G3-CAP cause significant adverse events. DP and WP result in different patterns of G3-CAP and management strategies should be based on this classification.

Epidemiology and management of aortic disease: aortic aneurysms and acute aortic syndromes.

The aorta is the 'greatest artery', through which oxygenated blood is delivered from the left ventricle to end organs with each cardiac cycle (200 million litres of blood transported in an average lifetime). The aorta can be affected by a wide spectrum of acute factors (such as cocaine use, weight lifting and trauma) and chronic acquired and/or genetic conditions (such as systemic arterial hypertension and phaeochromocytoma), which variously lead to increased aortic wall stress. The medial layer of the aorta can also be subject to abnormalities (such as Marfan syndrome, bicuspid aortic valve, inflammatory vasculitis, atherosclerosis and infections). Despite important advances in diagnostic and therapeutic interventions, data derived from registries and population-based studies highlight that the burden of aortic diseases remains high. Therefore, specific resources need to be allocated to design and implement preventive strategies (healthy lifestyles, modifications to cardiovascular risk factors, and educational and screening programmes) at individual and community levels. In this Review, we discuss the epidemiology, management and outcomes of the most common aortic diseases, namely, aortic aneurysms and acute aortic syndromes.

"Incidence, clinical and angiographic characteristics, management and outcomes of coronary artery perforation at a high volume cardiac care center during percutaneous coronary intervention".

AIMS: To study the incidence, clinical and angiographic characteristics, management and outcomes of coronary artery perforation (CAP) during percutaneous coronary intervention (PCI) at a high volume center in South-east Asia. METHODS: Data from patients who had CAP during PCI from January 2016 to December 2019 at our center were collected. Clinical features, angiographic and procedural characteristics, their management and outcomes were analyzed retrospectively. RESULTS: A total of 40,696 patients underwent PCI during the study period and the incidence of CAP was 0.13% (n = 51). Mean age was 60.0 ± 10.8 years and 69% were males. CAP cases involved complex type B2/C lesions in 73%, calcified lesions in 58%, and chronic total occlusions in 25%. Majority of patients presented as acute coronary syndrome (65%) and STEMI was the most frequent indication for PCI (33%). Most of the CAPs were Ellis type II (33%) and III (55%). CAP most frequently occurred during post dilation (n = 20) and wire manipulation (n = 17). Majority were treated by prolonged balloon inflation (53%) and covered stents (33%). Pericardiocentesis was required in 19 patients to alleviate tamponade. In one patient coil embolisation was done and two patients required bail-out emergency cardiac surgery. Periprocedural myocardial infarction occurred in 6% and in-hospital mortality was 10%. All-cause mortality accrued to 14% at 30 days and 16% at 6 months. CONCLUSION: Although incidence of CAP in contemporary interventional practice remains low, the morbidity and mortality are considerable. Early recognition and management strategies tailored to the severity of perforation play a key role in achieving better outcomes.

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.

Safety and Costs of Endobronchial Ultrasound-Guided Nodal Aspiration and Mediastinoscopy.

BACKGROUND: There remains debate over the best invasive diagnostic modality for mediastinal nodal evaluation. Prior studies have limited generalizability and insufficient power to detect differences in rare adverse events. We compared the risks and costs of endobronchial ultrasound (EBUS)-guided nodal aspiration and mediastinoscopy performed for any indication in a large national cohort. METHODS: We conducted a retrospective study (2007-2015) with MarketScan, a claims database of individuals with employer-provided insurance in the United States. Patients who underwent multimodality mediastinal evaluation (n = 1,396) or same-day pulmonary resection (n = 2,130) were excluded. Regression models were used to evaluate associations between diagnostic modalities and risks and costs while adjusting for patient characteristics, year, concomitant bronchoscopic procedures, and lung cancer diagnosis. RESULTS: Among 30,570 patients, 49% underwent EBUS. Severe adverse events-pneumothorax, hemothorax, airway/vascular injuries, or death-were rare and invariant between EBUS and mediastinoscopy (0.3% vs 0.4%; P = .189). The rate of vocal cord paralysis was lower for EBUS (1.4% vs 2.2%; P < .001). EBUS was associated with a lower adjusted risk of severe adverse events (OR, 0.42; 95% CI, 0.32-0.55) and vocal cord paralysis (OR, 0.57; 95% CI, 0.54-0.60). The mean cost of EBUS was $2,211 less than mediastinoscopy ($6,816 vs $9,023; P < .001). After adjustment this difference decreased to $1,650 (95% CI, $1,525-$1,776). CONCLUSIONS: When performed as isolated procedures, EBUS is associated with lower risks and costs compared with mediastinoscopy. Future studies comparing the effectiveness of EBUS vs mediastinoscopy in the community at large will help determine which procedure is superior or if trade-offs exist.

Coronary artery perforation during chronic total occlusion percutaneous coronary intervention: epidemiology, mechanisms, management, and outcomes.

AIMS: The aim of this study was to describe the epidemiology, mechanisms, management, and outcomes of coronary artery perforation during chronic total occlusion (CTO) percutaneous coronary intervention (PCI). METHODS AND RESULTS: We included 1,811 consecutive patients undergoing CTO PCI at five centres between 2011 and 2018. Coronary perforation was observed in n=99 (5.5%). Patients with perforation were older, had a higher J-CTO score, more often required antegrade dissection/re-entry and the retrograde approach, and had lower success rates. The frequency of Ellis type I, II, III and III "cavity spilling" perforations was 11%, 46%, 28%, and 14%, respectively. In 48% of cases, perforation involved the CTO vessel, while the retrograde approach was responsible for 46% of cases. In 53% of cases perforations required intervention. The most frequently applied management strategies included clinical observation (47%), covered stent implantation (25%), balloon occlusion (9%), and coil/fat embolisation (9%). Tamponade was observed in 20/99 (20%) perforation cases. Ellis type III perforations were most frequently observed at the CTO site. These were accountable for 16/20 tamponades and 3/5 deaths. In-hospital mortality was 5.1% vs 0.3% in patients with versus those without perforation (p<0.001). Older age, occlusion length >20 mm, rotational atherectomy, antegrade dissection/re-entry, and the retrograde approach were independently associated with coronary perforation. Patients with perforation suffered an increased incidence of target vessel failure on short-term follow-up. CONCLUSIONS: Coronary perforation is observed in a non-negligible proportion of CTO PCIs, often requires intervention, and is associated with tamponade and mortality in a minority of patients. CTO vessel-related perforations are associated with the highest burden of morbidity and mortality.

Incidence, predictors, management and outcomes of coronary perforations.

OBJECTIVES: We examined the contemporary incidence, types, predictors, angiographic characteristics, management and outcomes of coronary perforation. BACKGROUND: Coronary perforation is a rare, but important, complication of percutaneous coronary intervention (PCI). There is lack of data on perforations stratified as large and distal vessel perforations. METHODS: Retrospective, observational cohort study of all patients who underwent PCI at a high volume, tertiary hospital between the years 2009 and 2016. Angiograms of all coronary perforation cases were reviewed to determine the mechanism, type, and management of perforation. Risk-adjusted periprocedural complication rates were compared between patients with and without coronary perforation. One-year mortality outcomes of patients with large vessel vs. distal vessel perforation were also examined. RESULTS: Coronary perforation occurred in 68 of 13,339 PCIs (0.51%) performed during the study period: 51 (75%) were large vessel perforations and 17 (25%) distal vessel perforations. Most (67%) large vessel perforations were due to balloon/stent inflation, whereas most (94%) distal vessel perforations were due to guidewire exit. Patients with coronary perforations had significantly higher risk for periprocedural complications (adjusted odds ratio 7.57; 95% CI: 4.22-13.50; P < 0.001). Only one patient with large vessel perforation required emergency cardiac surgery, yet in-hospital mortality was high with both large vessel (7.8%) and distal vessel (11.8%) perforations. CONCLUSIONS: Coronary perforation is an infrequent, but potentially severe PCI complication. Most coronary perforations are large vessel perforations. Although coronary perforations rarely lead to emergency cardiac surgery, both distal vessel and large vessel perforations are associated with high in-hospital mortality, highlighting the importance of prevention.

Optical coherence tomography assessment of incidence, morphological characteristics, and spontaneous healing course of edge dissections following percutaneous coronary intervention with stent implantation in patients with non-ST segment elevation myocardial infarction.

BACKGROUND: Stenting-induced edge dissections (ED) can be assessed in detail by optical coherence tomography (OCT). This study sought to investigate the incidence, morphological characteristics, and spontaneous healing course of OCT-identified EDs following drug-eluting stent (DES) implantation in a non-ST segment elevation myocardial infarction (NSTEMI) patient-population. METHODS: Acute vessel wall injury at the 5-mm stent adjacent distal and proximal reference segments was assessed by post-procedure OCT and intravascular ultrasound (IVUS) in n=97 NSTEMI-patients (n=97 lesions). Six months OCT follow-up was available in 82 patients (including 35 untreated post-procedure EDs). RESULTS: The overall incidence of post-procedure OCT-detected ED was 38 per 97 patients (39.2%), and 47 per 182 stent edges (25.8%). None of the EDs were angiographically visualizable, while 10 (21.3%) were visible on concomitant IVUS-analysis. Morphologically, there was a significant difference in plaque type present at ED-edges vs. non-ED-edges when assessed with OCT; (1) lipid-rich and calcified plaques: 80.9% vs. 57.0%, (2) fibrous plaques: 17.0% vs. 26.7%, and (3) normal coronary vessels: 2.1% vs. 16.3%, p<0.01. Plaqueburden, assessed by IVUS, was substantially larger at ED-containing borders: 54.5±10.0% vs. 43.7±11.6%, p=0.01. Three dissections (8.6%) were incompletely healed at 6-month OCT follow-up. None of the EDs caused cardiac events during the 6-month follow-up, however, 1 ED-patient had target lesion revascularization with PCI and DES-implantation in extension of the scheduled OCT-control. CONCLUSIONS: OCT-detected EDs were frequent after stent implantation due to NSTEMI, and the majority of these EDs healed without leading to an adverse prognosis at 6months.

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.

Assessment of internal mammary artery injury after blunt chest trauma: a literature review.

The occurrence, bleeding, and treatment of internal mammary artery (IMA) injury after blunt chest trauma have not been well described in the literature. We reviewed articles published from July 1977 to February 2014 describing IMA injury after blunt chest trauma in 49 patients. There was a predominant incidence in males and on the left side. Blunt trauma to the IMA can cause anterior mediastinal hematoma, hemothorax, pseudoaneurysm, arteriovenous fistula, and extra-pleural hematoma. Of the 49 patients studied, 20 underwent embolization, 22 underwent surgical operation, 4 were managed by clinical observation, and 3 had undescribed treatment. Different parts and extents of IMA injury, adjacent vein injury, as well as the integrity of the pleura determined differences in bleeding modality. Prompt diagnosis, complete hemostasis, aggressive resuscitation, and multidisciplinary teams are recommended for patients with IMA injury.

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.

Medical liability insurance claims after treatment of varicose veins.

OBJECTIVE: Since insight into the reason for filing claims after treatment of varicose veins of the lower extremity might help prevent future claims, we determined the incidence of and reasons for medical liability insurance claims after such treatments in the Netherlands. METHOD: We performed a retrospective review of all medical liability insurance claims after varicose vein treatment handled by MediRisk between January 1993 and December 2007. RESULTS: A total of 144 claims were filed of which 104 were closed by the end of the study period. Nerve injury (n = 28), skin necrosis following sclerotherapy (n = 17), deep vein injury (n = 11) and insufficient communication (n = 9) accounted for more than 60% of all claims. Claims were equally distributed among registrars and consultants. Some 41 of the 104 closed claims were accepted. In 27 of the accepted cases, the physician had obviously failed in providing the care as expected from a medical practitioner allowed to perform these treatments. The majority of these 27 claims were due to injury of nerves (n = 11) or deep veins (n = 9). CONCLUSION: The incidence of claims after treatment of varicose veins in the Netherlands is low. Proper knowledge of anatomy and adequate communication, along with the introduction of less invasive treatments might prevent future claims.

[Minimal provider volume in total knee replacement : an analysis of the external quality assurance program of North Rhine-Westphalia (QS-NRW)]. / Mindestmengen in der Kniegelenkendoprothetik : Analyse der externen Qualitätssicherung für das Land Nordrhein-Westfalen.

BACKGROUND: A minimal provider volume for total knee replacement (TKR) was introduced in 2006. Does this lead to an improvenment in quality or not? The records of treatment in the compulsory external quality assurance program of the Land of North Rhine-Westphalia (QS-NRW) were evaluated. METHOD: A total of 125,324 comparable records from the QS-NRW program were available to determine the appearance of general and surgical complications. In a logistical regression model the risk factors age, gender, ASA classification, comorbidity and duration were taken into account. RESULTS: A significant reduction could only be shown for pneumonia, thrombotic events and lung embolisms as well as vascular injury. In 2006 and 2007 malpositioning of implants was significantly higher and from 2005 to 2008 the number of fractures rose compared to 2004. Deep infections and reoperations did not change significantly during the whole study period. CONCLUSION: This evaluation could not show an improvement in quality due to the minimal provider volume. Thus the minimal provider volume should not be taken into account as a main criterion to improve quality. Further outcome studies and creating an arthroplasty register in Germany are more useful.