Prevalence and outcome of abdominal vascular injury in severe trauma patients based on a TraumaRegister DGU international registry analysis.

This study details the etiology, frequency and effect of abdominal vascular injuries in patients after polytrauma based on a large registry of trauma patients. The impact of arterial, venous and mixed vascular injuries on patients' outcome was of interest, as in particular the relevance of venous vessel injury may be underestimated and not adequately assessed in literature so far. All patients of TraumaRegister DGU with the following criteria were included: online documentation of european trauma centers, age 16-85 years, presence of abdominal vascular injury and Abbreviated Injury Scale (AIS) ≥ 3. Patients were divided in three groups of: arterial injury only, venous injury only, mixed arterial and venous injuries. Reporting in this study adheres to the STROBE criteria. A total of 2949 patients were included. All types of abdominal vessel injuries were more prevalent in patients with abdominal trauma followed by thoracic trauma. Rate of patients with shock upon admission were the same in patients with arterial injury alone (n = 606, 33%) and venous injury alone (n = 95, 32%). Venous trauma showed higher odds ratio for in-hospital mortality (OR: 1.48; 95% CI 1.10-1.98, p = 0.010). Abdominal arterial and venous injury in patients suffering from severe trauma were associated with a comparable rate of hemodynamic instability at the time of admission. 24 h as well as in-hospital mortality rate were similar in in patients with venous injury and arterial injury. Stable patients suspected of abdominal vascular injuries should be further investigated to exclude or localize the possible subtle venous injury.

Damage control of peripheral vascular trauma - Don't be afraid of axillary or popliteal fosses.

Peripheral vascular injuries are uncommon in civilian trauma but can threaten the patient's life or the viability of the limb. The definitive control of the vascular injury represents a surgical challenge, especially if the patient is hemodynamically unstable. This article proposes the management of peripheral vascular trauma following damage control surgery principles. It is essential to rapidly identify vascular injury signs and perform temporary bleeding control maneuvers. The surgical approaches according to the anatomical injured region should be selected. We propose two novel approaches to access the axillary and popliteal zones. The priority should be to reestablish limb perfusion via primary repair or damage control techniques (vascular shunt or endovascular approach). Major vascular surgeries should be managed post-operatively in the intensive care unit, which will allow correction of physiological derangement and identification of those developing compartmental syndrome. All permanent or temporary vascular procedures should be followed by a definitive repair within the first 8 hours. An early diagnosis and opportune intervention are fundamental to preserve the function and perfusion of the extremity.

El trauma vascular periférico no es común en el contexto civil, pero representa una amenaza para la vida del paciente o de la extremidad. El control definitivo de la lesión vascular representa un desafío quirúrgico, especialmente en pacientes con inestabilidad hemodinámica. Este artículo describe la propuesta de manejo del trauma vascular periférico de acuerdo con los principios de la cirugía de control de daños. Se debe identificar los signos sugestivos de lesión vascular y realizar oportunamente maniobras temporales para el control del sangrado. Se debe elegir el abordaje quirúrgico dependiendo del área anatómica lesionada. Se proponen dos nuevas incisiones para acceder a la región axilar y poplítea. La prioridad es restablecer la perfusión de la extremidad mediante el reparo primario o técnicas de control de daños (shunt vascular o abordaje endovascular). Los pacientes sometidos a cirugías vasculares mayores deben ser manejados postoperatoriamente en la unidad de cuidados intensivos para corregir las alteraciones fisiológicas e identificar aquellos que desarrollen un síndrome compartimental. Todos los procedimientos vasculares permanentes o temporales deben contar con un reparo definitivo en las primeras 8 horas. El diagnóstico temprano e intervención oportuna son fundamentales para salvaguardar la perfusión y funcionalidad de la extremidad.

Literature review of peripheral vascular trauma: Is the era of intervention coming?

Traumatic peripheral vascular injury is a significant cause of disability and death either in civilian environments or on the battlefield. Penetrating trauma and blunt trauma are the most common forms of vascular injuries. Besides, iatrogenic arterial injury (IAI) is another pattern of vascular trauma. The management of peripheral vascular injuries has been improved in different environments and wars. There are different types of vascular injuries, such as vasospasm, contusion, intimal flaps, intimal disruption or hematoma, external compression, laceration, transection and focal wall defects, etc. The main clinical manifestations of vascular injuries are shock following massive hemorrhage and limb necrosis due to tissue and organ ischemia. Ultrasound, computed tomography angiography (CTA) and magnetic resonance angiography (MRA) are most valuable for assessment of peripheral vascular injuries. Angiography remains the gold standard for diagnosing vascular trauma. Immediate hemorrhage control and rapid restoration of blood flow are the primary goals of vascular trauma treatment. There are many operative treatment methods for vascular injuries, such as vascular suture or ligation, vascular wall repair and vascular reconstruction with blood vessel prostheses or vascular grafts. Embolization, balloon dilation and covered stent implantation are the main endovascular techniques. Surgical operation is still the primary treatment for vascular injuries. Endovascular treatment is a promising alternative, proved to be safe and effective, and preferred selection for patients. In summary, rapid diagnosis and timely surgical intervention remain the mainstays of the treatment. However, many issues need to be resolved by further studies.

Clinical classification and individualized design for the treatment of basicranial artery injuries.

This study aims to explore the principles of clinical classification and individualized treatment of basicranial artery injuries based on its anatomical correlation.The data of 172 patients with various types of basicranial artery injuries were retrospectively analyzed. Among these patients, 128 patients were male and 44 patients were female, and the average age of these patients was 28.3 years old. All patients underwent computed tomography, some patients underwent computed tomography angiography or magnetic resonance angiography, and all the diagnoses were confirmed by digital subtraction angiography (DSA). According to anatomical correlation, the injuries were classified into 5 types: vascular wall injury (type I), intradural injury (type II), epidural injury (type III), sinus injury (type IV), and skull base bone injury (type V). Individualized treatment was adopted based on the different types and characteristics of injuries.The percentages of basicranial artery injuries were as follows: type I, 4.6%; type II, 5.8%; type III, 3.5%; type IV, 77.9%; and type V, 8.1%. All 172 patients underwent DSA to demonstrate the classification. The lesion elimination rate revealed by DSA was 99.4% immediately after the operation, 98.3% at 1 week after the operation, and 98.8% at 3 months after the operation. The follow-up after 6 months revealed that the percentage of patients in whom clinical symptoms or signs completely disappeared was 97.7%, the percentage of patients with limited eye movement or visual impairment was 1.2%, and the percentage of patients with mild limb dysfunction was 0.6%.Basicranial artery injuries can be classified into 5 types. Individualized design of embolization therapy based on different characteristics might be applicable for basicranial artery injuries treatment.

Combat vascular injury: Influence of mechanism of injury on outcome.

BACKGROUND: Haemorrhage is the leading cause of death on the battlefield. Seventy percent of injuries are due to explosive mechanisms. Anecdotally, these patients have had poorer outcomes when compared to those with penetrating mechanisms of injury (MOI). We wished to test the hypothesis that outcomes following vascular reconstruction were worse in blast-injured than non blast-injured patients. METHODS: Retrospective cohort study. British and American combat casualties with arterial injuries sustained in Iraq or Afghanistan (2003-2014) were identified from the UK Joint Theatre Trauma Registry (JTTR). Eligibility included explosive or penetrating MOI, with follow-up to UK hospital discharge, or death. Outcomes were mortality, amputation, graft thrombosis, haemorrhage, and infection. Statistical analysis was performed using Pearson Chi-Square test, t-tests, ANOVA or non-parametric equivalent, and survival analyses. RESULTS: One hundred and fifteen patients were included, 80 injured by explosive and 35 by penetrating mechanisms. Evacuation time, ISS, number of arterial injuries, age and gender were comparable between groups. Seventy percent of arterial injuries resulted from an explosive MOI. The explosive injuries group received more blood products (p = 0.008) and suffered more regions injured (p < 0.0001). Early surgical interventions in both were ligation (n = 36, 31%), vein graft (n = 33, 29%) and shunting (n = 9, 8%). Mortality (n = 12, 10%) was similar between groups. Differences in limb salvage rates following explosive (n = 17, 53%) vs penetrating (n = 13, 76.47%) mechanisms approached statistical significance (p = 0.056). Nine (28%) vein grafted patients developed complications. No evidence of a difference in the incidence of vein graft thrombosis was found when comparing explosive with non-explosive cohorts (p = 0.154). CONCLUSIONS: The recorded numbers of vein grafts following combat arterial trauma in are small in the JTTR. No statistically-significant differences in complications, including vein graft thrombosis, were found between cohorts injured by explosive and non-explosive mechanisms.

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.

Unified classification of open fractures: Based on Gustilo and OTA classification schemes.

BACKGROUND: The Orthopaedic Trauma Association (OTA) classification scheme for open fractures has improved precision, validity and reliability over the modified Gustilo classification system. However, it needs to be modified into a simple and practical classification system to gain widespread acceptance and application. MATERIAL AND METHODS: We devised a new "unified" classification of open fractures based on the Gustilo and OTA classification systems. The new classification was tested for interobserver reliability on five different fractures classified by 15 surgeons each using the Krippendorff's alpha. Preference of surgeons for the Gustilo, OTA and unified classifications was assessed. RESULTS: The new classification showed excellent interobserver reliability (α = 0.93). A significantly higher number of surgeons expressed preference for the new over the Gustilo and OTA classifications for routine clinical use. CONCLUSION: The new "unified" classification of open fractures has good validity, reliability and acceptability, and has the potential to replace all other existing classification systems.

Pearls and pitfalls in imaging of blunt traumatic thoracic aortic injury: a pictorial review.

Blunt thoracic aortic injury (TAI) occurs most frequently as a sequelae of high impact deceleration such as high-velocity road traffic accidents and falls from height. The burden of mortality and morbidity is high, however advances in pre-hospital care, diagnostic imaging and endovascular therapies have improved outcomes in this group of patients. Emergent treatment depends on accurate, early diagnosis by the radiologist. It is therefore of paramount importance that radiologists are familiar with both the direct (intimal flap, pseudoaneurysm, aortic contour irregularity and contrast extravasation) and indirect (periaortic haematoma) imaging findings of TAI. Furthermore, it is critical that technical (breathing artefact and cardiac motion artefact) as well as anatomical (ductus diverticulum, aortic spindle and mediastinal structures which imitate periaortic haematoma) pitfalls are recognised to avoid misdiagnosis. This pictorial review will help the diagnostic radiologist to recognise the patterns of injury and imaging features associated with TAI, as well as highlighting potential mimics when interrogating CTangiography (CTA) in major trauma.

Inter-rater reliability in the radiological classification of renal injuries.

INTRODUCTION: Although many radiologists invoke the surgical classification of renal injury proposed by the American Association for Surgery in Trauma (AAST), there has been only limited work on the role of the AAST system as an imaging stratification. The aim was to determine the inter-rater reliability (IRR) amongst radiologists and urologists using the AAST system. METHODS: A 1-year retrospective study of consecutive patients with computed tomography (CT) evidence of renal trauma managed at a Level 1 trauma center. Three radiologists and three urologists independently stratified the presentation CT findings according to the AAST renal trauma classification. Agreement between independent raters and mutually exclusive groups was determined utilizing weighted kappa coefficients. RESULTS: One hundred and one patients were included. Individual inter-observer agreements ranged from 54/101 (53.4%) to 62/101 (61.4%), with corresponding weighted kappa values from 0.61 to 0.69, constituting substantial agreement. Urologists achieved intra-disciplinary agreement in 49 cases (48.5%) and radiologists in 36 cases (35.6%). Six-reader agreement was achieved in 24 cases (23.7%). The AAST grade I injuries had the highest level of agreement, overall. CONCLUSION: The finding of substantial IRR amongst radiologists and urologists utilizing the AAST system supports continued use of the broad parameters of the AAST system, with some modification in specific categories with lower agreement.

Simple classification and clinical outcomes of angiographic dissection after balloon angioplasty for femoropopliteal disease.

OBJECTIVE: Angiographic dissection is considered to be associated with restenosis. However, little is known about the impact of the severity of angiographic dissection on future restenosis. METHODS: A total of 319 consecutive de novo femoropopliteal lesions were treated by balloon angioplasty alone. All of these lesions were divided into three groups: group A, no angiographic dissection; group B, mild dissection, the width of the dissection was less than one-third of the lumen; and group C, severe dissection, the width of the dissection was more than one-third of the lumen. Kaplan-Meier analysis estimated the primary patency rate at 3 years between the groups. RESULTS: The primary patency rates at 3 years were 66.0% in group A, 63.8% in group B, and 32.5% in group C (log-rank, P < .001). Cox proportional hazards analysis revealed that a lesion length >100 mm (hazard ratio, 1.734; 95% confidence interval, 1.099-2.735; P = .018) and severe angiographic dissection (hazard ratio, 1.956; 95% confidence interval, 1.276-2.997; P = .002) were predictors of primary patency loss at 3 years. When the lesions were divided into two groups according to the lesion length >100 mm or not, angiographic dissection had a larger impact on restenosis in a long lesion >100 mm (≤100 mm: 65.5% in group A, 75.6% in group B, and 48.0% in group C [log-rank, P = .015]; >100 mm: 68.8% in group A, 42.5% in group B, and 24.2% in group C [log-rank, P = .017]). CONCLUSIONS: Severe angiographic dissection was associated with future restenosis after balloon angioplasty for femoropopliteal lesions, but mild angiographic dissection was not. Angiographic dissection had more impact on future restenosis particularly in treated long lesions. Stents might not be necessary in short lesions with mild dissection.

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.

Classification and Surgical Repair of Injuries Sustained During Transvenous Lead Extraction.

BACKGROUND: Injuries to cardiac and venous structures during pacemaker and defibrillator lead extraction are serious complications that have been studied poorly. The incidence of these injuries is unknown but likely underestimated. No systematic multicenter review of these injuries or their management has been undertaken. METHODS AND RESULTS: We interrogated our mandatory administrative database for all excimer laser extractions that sustained a cardiac or venous injury in the province of British Columbia. Injuries were classified according to presentation and compared with respect to nature of injury, type of repair, utilization of cardiopulmonary bypass, and outcome. Of 1082 excimer laser extractions over 19 years, 33 sustained an injury (3.0%). The majority of injuries occurred in women (21/33; 63.6%), and median age of oldest lead extracted was 10.8 (7.5, 12.2) years. A type 1 presentation, defined as circulatory collapse, was found in 12/33 patients (36.4%). A type 2 presentation, defined as progressive hypotension responsive to treatment, was found in 20/33 patients (60.6%). Over half the patients had a moderate or large injury, and cardiopulmonary bypass was required in 13 patients with extensive injury. Despite the presence of devastating injuries, the immediate availability of aggressive salvage measures resulted in a survival of 87.9% of patients at 30 days. CONCLUSIONS: The immediate availability of a cardiovascular surgeon, perfusionist, and cardiopulmonary bypass pump facilitates lifesaving repair of injuries sustained during laser lead extraction. The size and complexity of injury correlates closely with the presentation, blood loss, and need for cardiopulmonary bypass to facilitate repair.

Call for a new classification system and treatment strategy in blunt aortic injury.

OBJECTIVE: The current Society for Vascular Surgery (SVS) classification scheme for blunt aortic injury (BAI) is descriptive but does not guide therapy. We propose a simplified classification scheme based on our robust experience with BAI that is descriptive and guides therapy. METHODS: Patients presenting with BAI between January 1999 and September 2014 were identified from our institution's trauma registry. We divided patients into eras by time. Era 1: before the first United States Food and Drug Administration (FDA)-approved thoracic endovascular aortic repair (TEVAR) device (1999-2005); era 2: FDA-approved TEVAR devices (2005-2010); and era 3: FDA-approved BAI-specific devices (2010-present). Baseline demographic information, Injury Severity Score, hospital details, and survival were collected and compared. Our classification scheme was minimal aortic injury, SVS grade 1 and 2; moderate aortic injury, SVS grade 3; and severe aortic injury, SVS grade 4. RESULTS: We identified 226 patients with a diagnosis of BAI: 75 patients in era 1, 84 in era 2, and 67 in era 3. Mean Injury Severity Score was 39.5 (range, 16-75). The BAI-related in-hospital mortality was significantly higher before endovascular introduction in era 1 (14.6% vs 4.8%; P = .03), but was not significantly different between eras 2 and 3 or before and after BAI-specific devices were introduced (P = .43). Of 146 patients (64.6%) who underwent aortic intervention, 91 underwent endovascular repair, and 55 underwent open repair. All but nine patients (94%) had a moderate or severe injury. Survival across all three eras of patients undergoing operative intervention was 80.2%. Survival in eras 2 and 3 was higher than in era 1 (86.4% vs 73.8%) but was not significant (P = .38). Of 47 patients in eras 2 and 3 with minimal aortic injury, 45 (96%) were managed nonoperatively, with no BAI-related deaths. After 2007, follow-up imaging was obtained in 38 patients (80%) with minimal aortic injury, and progression was not observed. Computed tomography scans showed the injury in 13 patients appeared stable, 19 had complete resolution (50%), and 6 had a decreasing size of injury. CONCLUSIONS: Our experience confirms that BAI-related mortality for patients who survive to presentation is now 5%. From our findings during the past 15 years, we propose simplification of the SVS grading criteria of BAI into minimal, moderate, and severe based on treatment differences among the three groups. Minimal aortic injury can be successfully managed nonoperatively without mandatory follow-up imaging. Moderate aortic injury can be managed semielectively with TEVAR, and severe aortic injury, requires emergency TEVAR.

Iatrogenic biliary injuries: identification, classification, and management.

Because it offers several advantages over open cholecystectomy, laparoscopic cholecystectomy has largely replaced open cholecystectomy for the management of symptomatic gallstone disease. The only potential disadvantage is a higher incidence of major bile duct injury. Although prevention of these biliary injuries is ideal, when they do occur, early identification and appropriate treatment are critical to improving the outcomes of patients suffering a major bile duct injury. This report delineates the key factors in classification (and its relationship to mechanism and management), identification (intraoperative and postoperative), and management principles of these bile duct injuries.

Should blunt segmental vascular renal injuries be considered an American Association for the Surgery of Trauma Grade 4 renal injury?

BACKGROUND: Renal segmental vascular injury (SVI) following blunt abdominal trauma is not part of the original American Association for the Surgery of Trauma (AAST) renal injury grading system. Recent recommendations support classifying SVI as an AAST Grade 4 (G4) injury. Our primary aim was to compare outcomes following blunt renal SVI and blunt renal collecting system lacerations (CSLs). We hypothesize that renal SVI fare well with conservative management alone and should be relegated a less severe renal AAST grade. METHODS: We retrospectively identified patients with SVI and G4 CSL admitted to a Level 1 trauma center between 2003 and 2010. Penetrating trauma was excluded. Need for surgical intervention, length of stay, kidney salvage (>25% renal preservation on renography 6-12 weeks after injury), and delayed complication rates were compared between the SVI and CSL injuries. Statistical analysis used χ, Fisher's exact, and t tests. RESULTS: A total of 56 patients with SVI and 88 patients with G4 CSL sustained blunt trauma. Age, Injury Severity Score (ISS), and length of stay were similar for the two groups. Five patients in each group died of concomitant, nonrenal injuries. In the G4 CSL group, 15 patients underwent major interventions, and 32 patients underwent minor interventions. Only one patient in the SVI group underwent a major intervention. The renal salvage rate was 85.7% following SVI versus 62.5% following CSL (p = 0.107). CONCLUSION: Overall, surgical interventions are significantly lower among the SVI cohort than the G4 CSL cohort. Further analysis using a larger cohort of patients is recommended before revising the current renal grading system. Adding SVI as a G4 injury could potentially increase the heterogeneity of G4 injuries and decrease the ability of the AAST renal injury grading system to predict outcomes, such as nephrectomy rate. LEVEL OF EVIDENCE: Epidemiologic study, level IV.

Validity of vascular trauma codes at major trauma centres.

BACKGROUND: The use of administrative databases in vascular injury research has been increasing, but the validity of the diagnosis codes used in this research is uncertain. We assessed the positive predictive value (PPV) of International Classification of Diseases, tenth revision (ICD-10), vascular injury codes in administrative claims data in Ontario. METHODS: We conducted a retrospective validation study using the Canadian Institute for Health Information Discharge Abstract Database, an administrative database that records all hospital admissions in Canada. We evaluated 380 randomly selected hospital discharge abstracts from the 2 main trauma centres in Toronto, Ont., St.Michael's Hospital and Sunnybrook Health Sciences Centre, between Apr. 1, 2002, and Mar. 31, 2010. We then compared these records with the corresponding patients' hospital charts to assess the level of agreement for procedure coding. We calculated the PPV and sensitivity to estimate the validity of vascular injury diagnosis coding. RESULTS: The overall PPV for vascular injury coding was estimated to be 95% (95% confidence interval [CI] 92.3-96.8). The PPV among code groups for neck, thorax, abdomen, upper extremity and lower extremity injuries ranged from 90.8 (95% CI 82.2-95.5) to 97.4 (95% CI 91.0-99.3), whereas sensitivity ranged from 90% (95% CI 81.5-94.8) to 98.7% (95% CI 92.9-99.8). CONCLUSION: Administrative claims hospital discharge data based on ICD-10 diagnosis codes have a high level of validity when identifying cases of vascular injury. LEVEL OF EVIDENCE: Observational Study Level III.

CONTEXTE: L'utilisation des bases de données administratives pour la recherche sur les lésions vasculaires est en hausse, mais la validité des codes diagnostiques utilisés dans ces recherches est incertaine. Nous avons évalué la valeur prédictive positive (VPP) des codes de lésions vasculaires de la dixième édition de la Classification internationale des maladies (CIM-10) qui figurent dans une base de données administrative ontarienne. MÉTHODES: Nous avons réalisé une étude de validation rétrospective à partir de la base de données de l'Institut canadien d'information sur la santé (ICIS) sur les congés des patients, une base de données administrative qui enregistre toutes les hospitalisations au Canada. Nous avons évalué 380 congés hospitaliers de 2 grands centres de traumatologie de Toronto, en Ontario, soit l'Hôpital St. Michael's et le Centre des sciences de la santé Sunnybrook, entre le 1er avril 2002 et le 31 mars 2010. Nous avons ensuite comparé ces dossiers aux dossiers hospitaliers des patients correspondants pour vérifier la concordance des codes attribués aux interventions. Nous avons calculé la VPP et la sensibilité pour estimer la validité des codes diagnostiques appliqués aux lésions vasculaires. RÉSULTATS: La VPP globale pour les codes de lésions vasculaires a été estimée à 95% (intervalle de confiance [IC] de 95% 92,3­96,8). Parmi les groupes de codes attribués aux lésions affectant le cou, le thorax, l'abdomen, les membres supérieurs et inférieurs, la VPP a varié de 90,8 (IC de 95% 82,2­95,5) à 97,4 (IC de 95% 91.0­99,3), tandis que la sensibilité a varié de 90% (IC de 95% 81,5­94,8) à 98,7% (IC de 95% 92,9­99,8). CONCLUSION: Les données administratives sur les congés hospitaliers basées sur les codes diagnostiques de la CIM 10 ont un degré de validité élevé pour ce qui est des lésions vasculaires. NIVEAU DE PREUVE: Étude d'observation Niveau III.

A new classification scheme for treating blunt aortic injury.

BACKGROUND: There are numerous questions about the treatment of blunt aortic injury (BAI), including the management of small intimal tears, what injury characteristics are predictive of death from rupture, and which patients actually need intervention. We used our experience in treating BAI during the past decade to create a classification scheme based on radiographic and clinical data and to provide clear treatment guidelines. METHODS: The records of patients admitted with BAI from 1999 to 2008 were retrospectively reviewed. Patients with a radiographically or operatively confirmed diagnosis (echocardiogram, computed tomography, or angiography) of BAI were included. We created a classification system based on the presence or absence of an aortic external contour abnormality, defined as an alteration in the symmetric, round shape of the aorta: (1) intimal tear (IT)-absence of aortic external contour abnormality and intimal defect and/or thrombus of <10 mm in length or width; (2) large intimal flap (LIF)-absence of aortic external contour abnormality and intimal defect and/or thrombus of ≥10 mm in length or width; (3) pseudoaneurysm-presence of aortic external contour abnormality and contained rupture; (4) rupture-presence of aortic external contour abnormality and free contrast extravasation or hemothorax at thoracotomy. RESULTS: We identified 140 patients with BAI. Most injuries were pseudoaneurysm (71%) at the isthmus (70%), 16.4% had an IT, 5.7% had a LIF, and 6.4% had a rupture. Survival rates by classification were IT, 87%; LIF, 100%; pseudoaneurysm, 76%; and rupture, 11% (one patient). Of the ITs, LIFs, and pseudoaneurysms treated nonoperatively, none worsened, and 65% completely healed. No patient with an IT or LIF died. Most patients with ruptures lost vital signs before presentation or in the emergency department and did not survive. Hypotension before or at hospital presentation and size of the periaortic hematoma at the level of the aortic arch predicted likelihood of death from BAI. CONCLUSIONS: As a result of this new classification scheme, no patient without an external aortic contour abnormality died of their BAI. ITs can be managed nonoperatively. BAI patients with rupture will die, and resources could be prioritized elsewhere. Those with LIFs do well, and currently, most at our institution are treated with a stent graft. If a pseudoaneurysm is going to rupture, it does so early. Hematoma at the arch on computed tomography scan and hypotension before or at arrival help to predict which pseudoaneurysms need urgent repair.