Contemporary outcomes of traumatic popliteal artery injury repair from the popliteal scoring assessment for vascular extremity injury in trauma study.

OBJECTIVE: Traumatic popliteal artery injuries are associated with the greatest risk of limb loss of all peripheral vascular injuries, with amputation rates of 10% to 15%. The purpose of the present study was to examine the outcomes of patients who had undergone operative repair for traumatic popliteal arterial injuries and identify the factors independently associated with limb loss. METHODS: A multi-institutional retrospective review of all patients with traumatic popliteal artery injuries from 2007 to 2018 was performed. All the patients who had undergone operative repair of popliteal arterial injuries were included in the present analysis. The patients who had required a major lower extremity amputation (transtibial or transfemoral) were compared with those with successful limb salvage at the last follow-up. The significant predictors (P < .05) for amputation on univariate analysis were included in a multivariable analysis. RESULTS: A total of 302 patients from 11 institutions were included in the present analysis. The median age was 32 years (interquartile range, 21-40 years), and 79% were men. The median follow-up was 72 days (interquartile range, 20-366 days). The overall major amputation rate was 13%. Primary repair had been performed in 17% of patients, patch repair in 2%, and interposition or bypass in 81%. One patient had undergone endovascular repair with stenting. The overall 1-year primary patency was 89%. Of the patients who had lost primary patency, 46% ultimately required major amputation. Early loss (within 30 days postoperatively) of primary patency was five times more frequent for the patients who had subsequently required amputation. On multivariate regression, the significant perioperative factors independently associated with major amputation included the initial POPSAVEIT (popliteal scoring assessment for vascular extremity injury in trauma) score, loss of primary patency, absence of detectable immediate postoperative pedal Doppler signals, and lack of postoperative antiplatelet therapy. Concomitant popliteal vein injury, popliteal injury location (P1, P2, P3), injury severity score, and tibial vs popliteal distal bypass target were not independently associated with amputation. CONCLUSIONS: Traumatic popliteal artery injuries are associated with a significant rate of major amputation. The preoperative POPSAVEIT score remained independently associated with amputation after including the perioperative factors. The lack of postoperative pedal Doppler signals and loss of primary patency were highly associated with major amputation. The use of postoperative antiplatelet therapy was inversely associated with amputation, perhaps indicating a protective effect.

Lower extremity vascular injuries caused by firearms have a higher risk of amputation and death compared with non-firearm penetrating trauma.

OBJECTIVE: Firearm injuries have traditionally been associated with worse outcomes compared with other types of penetrating trauma. Lower extremity trauma with vascular injury is a common presentation at many centers. Our goal was to compare firearm and non-firearm lower extremity penetrating injuries requiring vascular repair. METHODS: We analyzed the National Inpatient Sample from 2010 to 2014 for all penetrating lower extremity injuries requiring vascular repair based on International Classification of Diseases, Ninth Revision codes. Our primary outcomes were in-hospital lower extremity amputation and death. RESULTS: We identified 19,494 patients with lower extremity penetrating injuries requiring vascular repair-15,727 (80.7%) firearm injuries and 3767 (19.3%) non-firearm injuries. The majority of patients were male (91%), and intent was most often assault/legal intervention (64.3%). In all penetrating injuries requiring vascular repair, the majority (72.9%) had an arterial injury and 43.8% had a venous injury. Location of vascular injury included iliac (19.3%), femoral-popliteal (60%), and tibial (13.2%) vascular segments. Interventions included direct vascular repair (52.1%), ligation (22.1%), bypass (19.4%), and endovascular procedures (3.6%). Patients with firearm injuries were more frequently younger, black, male, and on Medicaid, with lower household income, intent of assault or legal action, and two most severe injuries in the same body region (P < .0001 for all). Firearm injuries compared with non-firearm injuries were more often reported to be arterial (75.5% vs 61.9%), to involve iliac (20.6% vs 13.7%) and femoral-popliteal vessels (64.7% vs 39.9%), to undergo endovascular repair (4% vs 2.1%), and to have a bypass (22.5% vs 6.5%; P < .05 for all). Firearm-related in-hospital major amputation (3.3% vs 0.8%; P = .001) and mortality (7.6% vs 4.2%; P = .001) were higher compared with non-firearm penetrating trauma. Multivariable analysis showed that injury by a firearm source was independently associated with postoperative major amputation (odds ratio, 4.78; 95% confidence interval, 2.07-11.01; P < .0001) and mortality (odds ratio, 1.74; 95% confidence interval, 1.14-2.65; P = .01). CONCLUSIONS: Firearm injury is associated with a higher rate of amputation and mortality compared with non-firearm injuries of the lower extremity requiring vascular repair. These data can continue to guide public health discussions about morbidity and mortality from firearm injury.

Assessment of the "Weekend Effect" in Lower Extremity Vascular Trauma.

BACKGROUND: Studies suggest that patients admitted on weekends may have worse outcomes as compared with those admitted on weekdays. Lower extremity vascular trauma (LEVT) often requires emergent surgical intervention and might be particularly sensitive to this "weekend effect." The objective of this study was to determine if a weekend effect exists for LEVT. METHODS: The National and Nationwide Inpatient Sample Database (2005-2014) was queried to identify all adult patients who were admitted with an LEVT diagnosis. Patient and hospital characteristics were recorded or calculated and outcomes including in-hospital mortality, amputation, length of stay (LOS), and discharge disposition were assessed. Independent predictors of outcomes were identified using multivariable regression models. RESULTS: There were 9,282 patients admitted with LEVT (2,866 weekend admissions vs. 6,416 weekday admissions). Patients admitted on weekends were likely to be younger than 45 years (68% weekend vs. 55% weekday, P < 0.001), male (81% weekend vs. 75% weekday, P < 0.001), and uninsured (22% weekend vs. 17% weekday, P < 0.001) as compared with patients admitted on weekdays. There were no statistically significant differences in mortality (3.8% weekend vs. 3.3% weekday, P = 0.209), amputation (7.2% weekend vs. 6.6% weekday, P = 0.258), or discharge home (57.4% weekend vs. 56.1% weekday, P = 0.271). There was no clinically significant difference in LOS (median 7 days weekend vs. 7 days weekday), P = 0.009. On multivariable regression analyses, there were no statistically significant outcome differences between the groups. CONCLUSIONS: This study did not identify a weekend effect in LEVT patients in the United States. This suggests that factors other than the day of admission may be important in influencing outcomes after LEVT.

Is endovascular repair the first choice for all blunt aortic injury? A real-world assessment.

Blunt thoracic aortic injury (BTAI) represents an infrequently encountered but lethal traumatic injury. Minimal aortic injuries are appropriately treated by medical management, while more severe injuries require endovascular or open repair. Rapidly evolving endovascular technology has largely supplanted open repair as first line operative intervention, however, the complexity of the severely injured blunt trauma patient can complicate management decisions. The development and implementation of an optimal consensus grading system and treatment algorithm for the management of BTAI is necessary and will require multi-institutional study.

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.

Vascular trauma in the Amazon: updating the challenge. / Trauma vascular na Amazônia: atualizando o desafio.

OBJECTIVE: to evaluate the epidemiological data of patients operated on due to vascular trauma at a referral hospital in Pará state, to determine the variables that increase the risk of death, and to make a comparative analysis with the results previously published by the same institution. METHODS: an analytical retrospective study was performed through data collection from patients operated due to vascular injuries, between March 2013 and March 2017. Demographic and epidemiological data, such as the mechanism and topography of the lesion, distance between the trauma site and the hospital, and type of treatment and complications, were analyzed. Multivariate analysis and logistic regression studies were performed, to evaluate significant dependence between some variables and death occurrence. RESULTS: two hundred and eighty eight patients with 430 lesions were studied; 92.7% were male, 49.7% were between 25 and 49 years old; 47.2% of all injuries were caused by firearm projectiles; 47.2% of the lesions were located in the upper limbs, 42.7% in the lower limbs, 8% in the cervical region, 3.1% in the thoracic region, and 0.7% in the abdominal region; 52.8% of the patients were hospitalized for seven days or less. Amputation was required in 6.9% of patients and there was mortality in 7.93% of the cases. CONCLUSION: distances greater than 200km were associated with prolonged hospitalization and greater probability of limb amputation. Significant correlation between death occurrence and arterial injury, vascular injury in the cervical region, and vascular injury in the thoracic region was found.

OBJETIVO: avaliar dados epidemiológicos dos pacientes operados por trauma vascular em hospital de referência para traumatismos vasculares do Estado do Pará, determinar as variáveis que aumentam o risco de óbito e fazer uma análise comparativa com os resultados previamente publicados pela mesma instituição. MÉTODOS: estudo retrospectivo analítico realizado através da coleta de dados de pacientes operados por lesões vasculares, entre março de 2013 e março de 2017. Foram analisados dados demográficos e epidemiológicos, como o mecanismo e topografia da lesão, distância entre o local do trauma e o hospital, tipo de tratamento e complicações. Foi feito ainda o estudo de uma matriz de correlação com regressão logística entre as variáveis e a ocorrência de óbito. RESULTADOS: foram estudados 288 pacientes, com 430 lesões; 92,7% era do sexo masculino, 49,7% entre 25 e 49 anos de idade; 47,2% das lesões foi ocasionada por projéteis de arma de fogo; 47,2% das lesões situava-se nos membros superiores, 42,7% nos membros inferiores, 8% em região cervical, 3,1% torácicas e 0,7% abdominais; 52,8% dos pacientes teve hospitalização por sete dias ou menos. Amputação foi necessária em 6,9% e a mortalidade foi 7,93%. CONCLUSÃO: distâncias superiores a 200km foram associadas à internação prolongada e maior probabilidade de amputação de membros. Foi encontrada correlação significativa entre a ocorrência de óbito e o fato de haver lesão arterial, lesão vascular na topografia cervical e lesão vascular na topografia torácica.

Trauma vascular na Amazônia: atualizando o desafio / Vascular trauma in the Amazon: updating the challenge

RESUMO Objetivo: avaliar dados epidemiológicos dos pacientes operados por trauma vascular em hospital de referência para traumatismos vasculares do Estado do Pará, determinar as variáveis que aumentam o risco de óbito e fazer uma análise comparativa com os resultados previamente publicados pela mesma instituição. Métodos: estudo retrospectivo analítico realizado através da coleta de dados de pacientes operados por lesões vasculares, entre março de 2013 e março de 2017. Foram analisados dados demográficos e epidemiológicos, como o mecanismo e topografia da lesão, distância entre o local do trauma e o hospital, tipo de tratamento e complicações. Foi feito ainda o estudo de uma matriz de correlação com regressão logística entre as variáveis e a ocorrência de óbito. Resultados: foram estudados 288 pacientes, com 430 lesões; 92,7% era do sexo masculino, 49,7% entre 25 e 49 anos de idade; 47,2% das lesões foi ocasionada por projéteis de arma de fogo; 47,2% das lesões situava-se nos membros superiores, 42,7% nos membros inferiores, 8% em região cervical, 3,1% torácicas e 0,7% abdominais; 52,8% dos pacientes teve hospitalização por sete dias ou menos. Amputação foi necessária em 6,9% e a mortalidade foi 7,93%. Conclusão: distâncias superiores a 200km foram associadas à internação prolongada e maior probabilidade de amputação de membros. Foi encontrada correlação significativa entre a ocorrência de óbito e o fato de haver lesão arterial, lesão vascular na topografia cervical e lesão vascular na topografia torácica.

ABSTRACT Objective: to evaluate the epidemiological data of patients operated on due to vascular trauma at a referral hospital in Pará state, to determine the variables that increase the risk of death, and to make a comparative analysis with the results previously published by the same institution. Methods: an analytical retrospective study was performed through data collection from patients operated due to vascular injuries, between March 2013 and March 2017. Demographic and epidemiological data, such as the mechanism and topography of the lesion, distance between the trauma site and the hospital, and type of treatment and complications, were analyzed. Multivariate analysis and logistic regression studies were performed, to evaluate significant dependence between some variables and death occurrence. Results: two hundred and eighty eight patients with 430 lesions were studied; 92.7% were male, 49.7% were between 25 and 49 years old; 47.2% of all injuries were caused by firearm projectiles; 47.2% of the lesions were located in the upper limbs, 42.7% in the lower limbs, 8% in the cervical region, 3.1% in the thoracic region, and 0.7% in the abdominal region; 52.8% of the patients were hospitalized for seven days or less. Amputation was required in 6.9% of patients and there was mortality in 7.93% of the cases. Conclusion: distances greater than 200km were associated with prolonged hospitalization and greater probability of limb amputation. Significant correlation between death occurrence and arterial injury, vascular injury in the cervical region, and vascular injury in the thoracic region was found.

Complications and revision amputation following trauma-related lower limb loss.

INTRODUCTION: Trauma-related amputations are a common cause of limb loss in the United States. Despite the military and public health impact of trauma-related amputations, distributions of various lower limb amputations and the relative frequency of complications and revision amputations have not been well described. We used the National Trauma Data Bank (NTDB) in order to investigate the epidemiology of trauma-related lower extremity amputations among civilians in U.S. trauma centers. MATERIALS AND METHODS: We conducted a secondary data analysis of the 2011-2012 NTDB research data sets, using means and frequencies to characterize the patient population and describe the distribution of major lower extremity amputations. Multivariable regression models were fit to identify predictors of major post-surgical complications, revision amputation, length of hospitalization, and in-hospital mortality. RESULTS: A total of 2879 patients underwent a major lower extremity amputation secondary to a trauma-related lower limb injury, representing 0.18% of all NTDB trauma admissions from 2011 to 2012. 80.4% were male and 67.6% were white. The three most frequent definitive amputations preformed included trans-tibial (46%), trans-femoral (37.5%), and through foot (7.6%). The average length of hospitalization for all amputees was 22.7days. Patients with at least one revision amputation stayed in the hospital approximately 5.5days longer than patients not needing a revision amputation. 1204 patients (41.8%) required at least one revision amputation. 27.5% of amputees experienced at least one major post-surgical complication. African Americans experienced a 49% higher major post-surgical complication incidence and stayed, on average, 2.5days longer in the hospital compared to whites. Injury severity score, age, hospital teaching status, presence of a crush injury, fracture location, presence of compartment syndrome, and experiencing a major post-surgical complication were all significant predictors of revision amputation. CONCLUSION: We report a high rate of complications and revision amputations among trauma-related lower limb amputees, and identify predictors of surgical outcomes that have not been described in the literature including African American race. Compartment syndrome is a significant predictor of major post-surgical complications, revision amputation, and length of hospitalization.

Racial disparities after vascular trauma are age-dependent.

OBJECTIVE: Different racial disparities exist between white and black all-cause trauma patients depending on their age group; however, the effects of race and age on outcomes after vascular trauma are unknown. We assessed whether the previously described age-dependent racial disparities after all-cause trauma persist in the vascular trauma population. METHODS: Vascular trauma patients were identified from the Nationwide Inpatient Sample (January 2005 to December 2012) using International Classification of Diseases-Ninth Edition codes. Univariable and multivariable analyses were used to compare in-hospital mortality and amputation for blacks vs whites for younger (16-64 years) and older (≥65 years) age groups. RESULTS: Black patients (n = 937) were younger, more frequently male, without insurance, and suffered from more penetrating and nonaccidental injuries than white patients (n = 1486; P < .001). On univariable analysis, blacks had a significantly higher risk of death (odds ratio, [OR], 1.78; 95% confidence interval [CI], 1.16-2.74) and a significantly lower risk of amputation (OR, 0.54; 95% CI, 0.38-0.77), but these differences were not sustained after adjusting for baseline differences between groups. When stratified by age, there were significant racial disparities in mortality and amputation on univariable analysis. After risk adjustment, these differences persisted in the older group (mortality: OR, 5.95; 95% CI, 1.42-25.0; amputation: OR, 4.21; 95% CI, 1.28-13.6; P < .001) but not the younger group (mortality: OR, 1.31; 95% CI, 0.71-2.42; amputation: OR, 0.92; 95% CI, 0.58-1.46; P = not significant). Differences in survival and amputation after vascular trauma appear to be related to a higher prevalence of nonaccidental penetrating injuries in the younger black population. Race was the single greatest predictor of poor outcomes in the older population (P ≤ .008). CONCLUSIONS: Older black patients are nearly five-times more likely to experience death or amputation after vascular trauma than their white counterparts. Contrary to reports suggesting that younger white patients have better outcomes after all-cause trauma than younger black patients, racial disparities among patients with traumatic vascular injuries appear to be confined to the older age group after risk adjustment.

Management of Vascular Injury during Current Peaceful Yemeni Revolution.

BACKGROUND: To provide a complete review of our experience on the observed vascular injuries patterns during contemporary Yemeni revolution, management strategies used in the care of injuries and to highlight lessons learned from that period. METHODS: From February 2011 to January 2012, all casualties evaluated at Yemen International Hospital, were prospectively entered into a database and retrospectively reviewed. Data collected included site, type, and mechanism of vascular injury, associated trauma, type of vascular repair; initial outcome, amputation rate, and complication. RESULTS: Of 2,200 injured patients evacuated from field hospital, vascular injuries occurred in 63 patients, and these patients comprised the study group. Fifty-one (80.9%) patients were wounded by gunshots high velocity, 6 (9.5%) were wounded by gunshots low velocity, and 6 (9.5%) experienced explosive devices injury. Most of injuries 55 (87%) occurred in the extremities 45 (71%) in the lower extremities and 10 (16%) in the upper extremities, 3 (5%) in carotid arteries, 3 (5%) in internal iliac arteries, and 2 (3%) in internal jugular vein. Nearly half 31 (49%) of the patients sustained complex vascular injuries (arterial and venous injuries), isolated arterial injuries 28 (45%), and isolated venous injuries 4 (6%). Twenty (32%) of the patients underwent complete revascularization and 11 (15%) just arterial repair with venous ligation. According arterial management 32 (51%) of patients underwent revascularization with venous graft, 18 (29%) repaired by end-to-end anastomosis, 1 (2%) polytetrafluorethylene, 7 (11%) thrombectomy, and 5 (8%) arterial ligation. Vascular injuries were associated with bony fracture in 33 (52%) of patients. Postoperative wound infection occurred in 9 (14%) patients. Of those, 7 had venous ligation. Secondary amputation and mortality rates during the study period were 3 (5%) and 4 (6%), respectively. CONCLUSIONS: This report represents the first analysis of vascular injuries during contemporary Yemeni revolution in Taiz city. Vascular injuries occurred in 3% of revolution-related injured patients. Our secondary amputation rate of extremities was 5%. Management of arterial repair with autologous vein graft remains the treatment of choice. Ligation of venous injured in a watershed area, such an iliofemoral and popliteal vein should be avoided to prevent leg phlegmasia.

The effect of loss to follow-up on treatment of blunt traumatic thoracic aortic injury.

OBJECTIVE: Loss to follow-up (LTFU) can be a major difficulty for any clinical research study. The objective of this systematic review was to assess the extent of LTFU and its potential effect in studies of adult trauma patients with blunt thoracic aortic injuries (BTAIs). METHODS: Studies comparing management of BTAIs were systematically reviewed. Duplicate independent review was used for study selection, data abstraction, and critical appraisals. RESULTS: Thirty-six studies were included for synthesis, of which 94.1% applied a retrospective cohort design to prospective institutional databases. The mean LTFU at 1 year was 26.5% ± 31.6% for endovascular repair and 20.6% ± 34.2% for open repair groups. Not having a surgical/interventional specialist as a first or senior author was associated with a 39.7% higher LTFU at 1 year (P = .002). Studies with a higher risk of bias, later publication year, or North American origin were associated with a significantly higher risk for LTFU at 1 year (P ≤ .001). Nearly half of included studies assessed in-hospital outcomes exclusively. Only 38.2% explicitly reported LTFU data. Eight studies explicitly described the method of dealing with LTFU: eight used survival analysis and one used a national Social Security Death Index. Sensitivity analyses using plausible worst-case LTFU scenarios resulted in 14% to 17% of studies changing direction of effect. CONCLUSIONS: There is significant LTFU in trauma studies comparing operative methods for BTAIs. LTFU is generally handled and reported suboptimally, and sensitivity analyses suggest that study results are sensitive to differential LTFU. This has implications for the evidence-based choice of the operative method. Some protective factors that may aid in reducing LTFU were identified, one of which was involvement of a surgical or interventional specialist as a key author.

Outcomes of endovascular repair for patients with blunt traumatic aortic injury.

BACKGROUND: Traumatic aortic injury (TAI) remains a leading cause of death after blunt force. Thoracic endovascular aortic repair (TEVAR) has been widely adopted as an alternative to open repair for the treatment of TAI. Although significant short-term benefits have been demonstrated for patients undergoing TEVAR, longer-term follow-up data are lacking. METHODS: Trauma registry data were analyzed. Follow-up data were gathered from a combination of medical records, imaging, telephone interviews, and Social Security Death Index. Primary outcomes were in-hospital mortality, stroke, and paraplegia. Secondary outcomes included device-related adverse events (rupture, migration, or endoleak), secondary procedures, open conversion, and all-cause mortality. RESULTS: Between September 2005 and July 2012, 82 consecutive patients (57 males, mean [SD] age, 39.5 [20] years; mean [SD] Injury Severity Score [ISS], 34 [9.5]) underwent TEVAR for TAI. A total of 87 devices were implanted: TAG (n = 36), CTAG (n = 12) (WL Gore, Flagstaff, AZ); Talent (n = 29), Valiant (n = 5) (Medtronic, Santa Rosa, CA); TX2 (n = 2) (Cook, Bloomington, IN); and other (n = 3). Left subclavian artery coverage was required in 32 patients (39%). Technical success rate was 100%. Rates of in-hospital mortality, stroke, and paraplegia were 5.0%, 2.4%, and 0%, respectively.Median follow-up time was 2.3 years (range, 0-7 years). The availability of follow-up data was as follows: Social Security Death Index (100%), telephone interview (68%), clinic visit (61%), and imaging (82%). The incidence of device-related adverse events was 2.4%. There were four secondary procedures: two patients underwent a carotid-subclavian bypass, and two had an open conversion for device-related complications. Survival was 95% at 30 days, 88% at 1 year, 87% at 2 years, and 82% at 5 years. CONCLUSION: At midterm follow-up, TEVAR is an effective and durable option for the treatment of TAI in properly selected patients. Device-related adverse events, secondary procedures, and open conversion are rare. Follow-up remains a challenge. LEVEL OF EVIDENCE: Therapeutic study, level V.

Current optimal assessment and management of carotid and vertebral spontaneous and traumatic dissection.

Dissection of the internal carotid or vertebral artery has been recognized as a cause of stroke in young patients. It is disproportionate in its representation as a cause of stroke in this age group. Intimal tears, intramural hematomas, and dissection aneurysms may be the result of trauma or may occur spontaneously. Spontaneous dissection may be the result of inherent arterial weakness or in association with other predisposing factors. Clinical diagnosis is often difficult, but increased awareness and a range of modern investigations such as computerized tomography or magnetic resonance imaging may aid in diagnosis. Management options include antiplatelet therapy, anticoagulation, thrombolysis, and surgical or endovascular procedures. Prognosis is variable, and dissection may be asymptomatic but may lead to profound neurological deficit and death.

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.

Coronary perforation in the drug-eluting stent era: incidence, risk factors, management and outcome: the UK experience.

AIMS: Coronary perforation during percutaneous coronary intervention (PCI) is associated with a high risk of mortality and morbidity. However there has been little data on perforation in the current era despite significant changes in PCI practice. We set out to identify incidence, risk factors and management strategies of coronary perforation in the current era. METHODS AND RESULTS: We performed a retrospective analysis of the Manchester Heart Centre PCI database from June 2004 to May 2008. Detailed analysis of all cases of suspected perforation was undertaken by case note and angiographic review. Demographic data was collected regarding all patients undergoing intervention. A total of 12,729 coronary lesions were treated in 7,903 patients over four years, during which drug-eluting stent (DES) uptake was 77%. The incidence of perforation was 0.56% (44/12,729). Perforation was associated with an inpatient mortality of 15.9% (7/44). Factors associated with perforation were female sex (p=0.003), increasing age (p<0.01), coronary calcification (p=0.003), use of a cutting balloon (p<0.001) or atheroablation (p<0.001), and treatment of a chronic total occlusion (p<0.01). Factors associated with death after perforation were non-elective procedure (p=0.036) and pericardial drain insertion (p<0.001). CONCLUSIONS: Despite treatment of more complex disease, the incidence of coronary perforation has not increased. Major perforations (Ellis class III) are associated with a high rate of emergency coronary artery bypass graft (CABG) and death. Endovascular treatments allow sealing of the perforation in most cases and deaths occur primarily as a result of cardiogenic shock due to occlusion of the culprit artery. Patient risk factors associated with perforation should be considered when planning or performing PCI.

Incidence, predictors, management, immediate and long-term outcomes following grade III coronary perforation.

OBJECTIVES: The aim of this study was to evaluate the incidence, predictors, management, and clinical outcomes in patients with grade III coronary perforation during percutaneous coronary intervention. BACKGROUND: Grade III coronary perforation is a rare but recognized complication associated with high morbidity and mortality. METHODS: From 24,465 patients undergoing percutaneous coronary intervention from May 1993 to December 2009, 56 patients had grade III coronary perforation. RESULTS: Most lesions were complex: 44.6% type B2, 51.8% type C, and 28.6% chronic total occlusions, and within a small vessel (≤ 2.5 mm) in 32.1%. Glycoprotein IIb/IIIa inhibitors were administered in 17.9% of patients. The device causing perforation was intracoronary balloon in 50%: 53.6% compliant, 46.4% noncompliant; intracoronary guidewire in 17.9%; rotablation in 3.6%; and directional atherectomy in 3.6%. Following perforation, immediate treatment and success rates, respectively, were prolonged balloon inflation 58.9%, 54.5%; covered stent implantation 46.4%, 84.6%; coronary artery bypass graft surgery (CABG) and surgical repair 16.0%, 44.4%; and coil embolization 1.8%, 100%. Multiple methods were required in 39.3%. During the procedure (n = 56), 19.6% required cardiopulmonary resuscitation and 3.6% died. In-hospital (n = 54), 3.7% required CABG, 14.8% died. The combined procedural and in-hospital myocardial infarction rate was 42.9%, and major adverse cardiac event rate was 55.4%. At clinical follow-up (n = 46) (median: 38.1 months, range 7.6 to 122.8), 4.3% had a myocardial infarction, 4.3% required CABG, and 15.2% died. The target lesion revascularization rate was 13%, with target vessel revascularization in 19.6%, and major adverse cardiac events in 41.3%. CONCLUSIONS: Grade III coronary perforation is associated with complex lesions and high acute and long-term major adverse cardiac event rates.

Existing trauma and critical care scoring systems underestimate mortality among vascular trauma patients.

BACKGROUND: The impact of vascular injuries on patient mortality has not been well evaluated in multi-trauma patients. This study seeks to determine (1) whether the presence of vascular trauma negatively affects outcome compared with nonvascular trauma (NVT) and (2) the utility of existing severity scoring systems in predicting mortality among vascular trauma (VT) patients. METHODS: A retrospective review of our trauma database from January 2005 to December 2007 was conducted. Demographics, Injury Severity Scores (ISS), Revised Trauma Scores (RTS), Trauma Score-Injury Severity Scores (TRISS), Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, and mortality rates were compared. Control patients were selected from a matching cohort based on ISS. Comparisons were made between groups based on the above scoring systems. Statistical analysis used χ(2) analysis and Student t-tests. RESULTS: Fifty VT and 50 NVT patients were identified with no significant differences in age, gender, mechanism of injury, ISS, RTS, or TRISS. The mean APACHE II score was higher in VT compared with NVT (12.3 vs 8.8, P < .05). Overall mortality was higher in VT compared with NVT but did not reach statistical significance (24% vs 11.8%, P = .108). VT patients with RTS score >5 had a higher mortality rate (26% vs 2.2%, P = .007). VT patients with an ISS score >24 had a higher mortality compared with NVT patients (61% vs 28.6%, P = .04). VT patients with an APACHE II score <14 also had a higher mortality rate (18.2% vs 0%, P = .007). Finally, VT patients with a TRISS probability of survival of >80% had a higher mortality rate (13.9% vs 0%, P = .05). CONCLUSIONS: In multi-trauma patients, the presence of vascular injury was associated with increased mortality in less severely injured patients based on the RTS, TRISS, and APACHE II scores. These scoring systems underestimated mortality in patients with vascular trauma. Level of care and future trauma algorithms should be adjusted in the presence of vascular trauma.