Long-term functional outcomes of upper extremity civilian vascular trauma.

OBJECTIVE: Civilian analyses of long-term outcomes of upper extremity vascular trauma (UEVT) are limited. Our goal was to evaluate the management of UEVT in the civilian trauma population and explore the long-term functional consequences. METHODS: A retrospective review and analysis was performed of patients with UEVT at an urban Level 1 trauma center (2001-2022). Management and long-term functional outcomes were analyzed. RESULTS: There were 150 patients with UEVT. Mean age was 34 years, and 85% were male. There were 42% Black and 27% White patients. Mechanism was penetrating in 79%, blunt in 20%, and multifactorial in 1%. Within penetrating trauma, mechanism was from firearms in 30% of cases. Of blunt injuries, 27% were secondary to falls, 13% motorcycle collisions, 13% motor vehicle collisions, and 3% crush injuries. Injuries were isolated arterial in 62%, isolated venous in 13%, and combined in 25% of cases. Isolated arterial injuries included brachial (34%), radial (27%), ulnar (27%), axillary (8%), and subclavian (4%). The majority of arterial injuries (92%) underwent open repair with autologous vein bypass (34%), followed by primary repair (32%), vein patch (6.6%), and prosthetic graft (3.3%). There were 23% that underwent fasciotomies, 68% of which were prophylactic. Two patients were managed with endovascular interventions; one underwent covered stent placement and the other embolization. Perioperative reintervention occurred in 12% of patients. Concomitant injuries included nerves (35%), bones (17%), and ligaments (16%). Intensive care unit admission was required in 45%, with mean intensive care unit length of stay 1.6 days. Mean hospital length of stay was 6.7 days. Major amputation and in-hospital mortality rates were 1.3% and 4.6% respectively. The majority (72%) had >6-month follow-up, with a median follow-up period of 197 days. Trauma readmissions occurred in 19%. Many patients experienced chronic pain (56%), as well as motor (54%) and sensory (61%) deficits. Additionally, 41% had difficulty with activities of daily living. Of previously employed patients (57%), 39% experienced a >6-month delay in returning to work. Most patients (82%) were discharged with opioids; of these, 16% were using opioids at 6 months. CONCLUSIONS: UEVT is associated with long-term functional impairments and opioid use. It is imperative to counsel patients prior to discharge and ensure appropriate follow-up and therapy.

Higher stroke risk after carotid endarterectomy and transcarotid artery revascularization is associated with relative surgeon volume ratio.

OBJECTIVE: Adoption of transcarotid artery revascularization (TCAR) by surgeons has been variable, with some still performing traditional carotid endarterectomy (CEA), whereas others have shifted to mostly TCAR. Our goal was to evaluate the association of relative surgeon volume of CEA to TCAR with perioperative outcomes. METHODS: The Vascular Quality Initiative CEA and carotid artery stent registries were analyzed from 2021 to 2023 for symptomatic and asymptomatic interventions. Surgeons participating in both registries were categorized in the following CEA to CEA+TCAR volume percentage ratios: 0.25 (majority TCAR), 0.26 to 0.50 (more TCAR), 0.51 to 0.75 (more CEA), and 0.76 to 1.00 (majority CEA). Primary outcomes were rates of perioperative ipsilateral stroke, death, cranial nerve injury, and return to the operating room for bleeding. RESULTS: There were 50,189 patients who underwent primary carotid revascularization (64.3% CEA and 35.7% TCAR). CEA patients were younger (71.1 vs 73.5 years, P < .001), with more symptomatic cases, less coronary artery disease, diabetes, and lower antiplatelet and statin use (all P < .001). TCAR patients had lower rates of smoking, obesity, and dialysis or renal transplant (all P < .001). Postoperative stroke after CEA was significantly impacted by the operator CEA to TCAR volume ratio (P = .04), with surgeons who perform majority TCAR and more TCAR having higher postoperative ipsilateral stroke (majority TCAR odds ratio [OR]: 2.15, 95% confidence interval [CI]: 1.16-3.96, P = .01; more TCAR OR: 1.42, 95% CI: 1.02-1.96, P = .04), as compared with those who perform majority CEA. Similarly, postoperative stroke after TCAR was significantly impacted by the CEA to TCAR volume ratio (P = .02), with surgeons who perform majority CEA and more CEA having higher stroke (majority CEA OR: 1.51, 95% CI: 1.00-2.27, P = .05; more CEA OR: 1.50, 95% CI: 1.14-2.00, P = .004), as compared with those who perform majority TCAR. There was no association between surgeon ratio and perioperative death, cranial nerve injury, and return to the operating room for bleeding for either procedure. CONCLUSIONS: The relative surgeon CEA to TCAR ratio is significantly associated with perioperative stroke rate. Surgeons who perform a majority of one procedure have a higher stroke rate in the other. Surgeons offering both operations should maintain a balanced practice and have a low threshold to collaborate as needed.

Outcomes of Trauma Patients with Flail Chest and Surgical Rib Stabilization.

The goal of this project was to describe the current practices of this institution and identify which patients benefit from surgical stabilization of rib fractures (SSRF). A total of 1429 trauma patients admitted to our Level 1 center with rib fractures between January 1, 2014 and June 22, 2020 were retrospectively reviewed. Flail chest was observed in 43 (3.01%) patients. Surgical stabilization of rib fractures was pursued in 27 of all patients (1.89%). Twenty-four flail chest patients required intubation (ETT). Nineteen were not intubated (NoET). Of the ETT group, 8 underwent SSRF and 16 did not. Those who had SSRF had a shorter ventilator Length of Stay (7.1 vs 15.7 d) and Intensive Care Unit Length of Stay (9.8 vs 11.9 d). Surgical stabilization of rib fractures has shown success in managing flail chest. In intubated patients with flail chest, fixation seems to decrease Intensive Care Unit stays and the duration of ventilation. We believe we need to perform SSRF on more patients with flail chest.

Gastrointestinal Bleeding in Mechanical Cardiac Support.

BACKGROUND: Mechanical cardiac support (MCS) is a lifesaving therapy option in patients with heart failure and other medical disorders. However, there is an associated risk of gastrointestinal bleeding (GIB). The goal of this study was to determine GIB incidence and associated risk factors. METHODS: All patients at one institution from 2009 to 2018 under durable and nondurable support were retrospectively reviewed for GIB during their MCS period. Clinical records were evaluated for patient demographics, GIB characteristics, and interventions. Univariate and multivariate analyses were performed to compare patient groups. RESULTS: A total of 427 patients were reviewed, with 111 (25.9%) patients representing 218 episodes of GIB during our study period. The incidence rate from support initiation to GIB was 44.9% by 6 months and 60.6% in 12 months, occurring at a mean of 216.7 days. Higher rates of bleeding were found in patients with hypertension (82% vs 71.5%; P = .03) and diabetes mellitus (62.2% vs 38.3%; P < .0001), as well as pulmonary (48.7% vs 35.4%; P = .014), hepatic (21.6% vs 10.4%; P = .003), and renal disease (48.7% vs 37.3%; P = .037). Endoscopy revealed an upper GI source in 56% (n = 123) of bleeds. The most common etiology of bleeding included angiodysplasia/vascular malformation (35.7%). Therapeutic intervention was performed in 109 (50%) cases, with only 1 surgical intervention. DISCUSSION: Overall, GIB can be a significant adverse event in patients under mechanical cardiac support, so proper management of anticoagulation and early endoscopy evaluation remains of great importance.