The elimination of anastomosis in open trauma vascular reconstruction: A novel technique using an animal model.

BACKGROUND: The standard approach to vascular trauma involves arterial exposure and reconstruction using either a vein or polytetrafluoroethylene graft. We have developed a novel technique to repairing arterial injuries by deploying commercially available vascular stents through an open approach, thus eliminating the need for suture anastomosis. The objective of this study was to evaluate the feasibility, stent deployment time (SDT), and stent patency of this technique in a ewe vascular injury model. METHODS: After proximal and distal control, a 2-cm superficial femoral arterial segment was resected in 8 Dorper ewes to simulate an arterial injury. Two stay sutures were placed in the 3- and 9-o'clock positions of the transected arterial ends to prevent further retraction. Ten milliliters of 10-IU/mL heparinized saline was flushed proximally and distally. An arteriotomy was then created 2.5 cm from the transected distal end through which we deployed Gore Viabahn stents with a 20% oversize and at least 1-cm overlap with the native vessel on either end. The arteriotomy was then closed with 3 (1) interrupted 6-0 Prolene sutures. The ewes were fed acetylsalicylic acid 325 mg daily. Duplex was performed at 2 months postoperatively to evaluate stent patency. SDT was defined as time from stay suture placement to arteriotomy closure. RESULTS: The 8 ewes weighed a mean (SD) of 34.4 (4.3) kg. The mean (SD) superficial femoral arterial was 4.3 (0.6) mm. Six 5 mm × 5 cm and two 6 mm × 5 cm Gore Viabahn stents were deployed. The mean (SD) SDT was 34 (19) minutes, with a trend toward less time with increasing experience (SDTmax, 60 minutes; SDTmin, 10 minutes). Duplex performed at 2 months postoperatively showed stent patency in five of eight stents. There was an association between increasing SDT and stent thrombosis. CONCLUSION: Open deployment of commercially available vascular stents to treat vascular injuries is a conceptually sound and technically feasible alternative to standard open repair. Larger studies are needed to refine this technique and minimize stent complications, which are likely technical in nature.

Early thromboembolic prophylaxis in patients with blunt solid abdominal organ injuries undergoing nonoperative management: is it safe?

BACKGROUND: The aim of this study was to compare the safety of early (≤48 hours), intermediate (48 to 72 hours), and late (≥72 hours) venous thromboembolism prophylaxis in patients with blunt abdominal solid organ injury managed nonoperatively. METHODS: We performed a 6-year (2006 to 2011) retrospective review of all trauma patients with blunt abdominal solid organ injuries. Patients were matched using propensity score matching in a 2:1:1 (early:intermediate:late) for age, gender, systolic blood pressure, Glasgow Coma Scale, Injury Severity Score, and type and grade of organs injured. Our primary outcome measures were: hemorrhage complications and need for intervention (operative intervention and/or angioembolization). RESULTS: A total of 116 patients (58 early, 29 intermediate, and 29 late) were included. There were no differences in age (P = .5), Injury Severity Score (P = .6), type (P = .1), and grade of injury of the organ (P = .6) between the 3 groups. There were 67 liver (43.2%), 63 spleen (40.6%), 49 kidney (31.6%), and 24 multiple solid organ (15.4%) injuries. There was no difference in operative intervention (P = .8) and postprophylaxis blood transfusion (P = .3) between the 3 groups. CONCLUSIONS: Early enoxaparin-based anticoagulation may be a safe option in trauma patients with blunt solid organ injury. This study showed no significant correlation between early anticoagulation and development of bleeding complications.

Blunt chest trauma.

Blunt aortic injury is the most lethal injury of the thorax, of which aortic transection is the second leading cause of death. Pseudoaneurysm formation is seen in patients who survive the injury and arrive to the emergency department with small or partial-thickness tears of the aorta. In general, the proximal descending aorta is most commonly afflicted due to the relatively mobile aortic arch moving against the fixed descending aorta. There are several factors associated with a high risk of aortic injury including high-speed motor vehicle collision (MVC) accidents, unrestrained drivers and passengers, extensive impact/collision and abrupt deceleration of motor vehicles. In this case study, a 28-year-old male patient with a thoracic aorta injury is presented. Diagnostic findings consistent with transection and/or dissection and a review of his surgical management are also discussed.

Repeal of the concealed weapons law and its impact on gun-related injuries and deaths.

BACKGROUND: Senate Bill 1108 (SB-1108) allows adult citizens to carry concealed weapons without a permit and without completion of a training course. It is unclear whether the law creates a "deterrent factor" to criminals or whether it escalates gun-related violence. We hypothesized that the enactment of SB-1108 resulted in an increase in gun-related injuries and deaths (GRIDs) in southern Arizona. METHODS: We performed a retrospective cohort study spanning 24 months before (prelaw) and after (postlaw) SB-1108. We collected injury and death data and overall crime and accident trends. Injured patients were dichotomized based on whether their injuries were intentional (iGRIDs) or accidental (aGRIDs). The primary outcome was any GRID. To determine proportional differences in GRIDs between the two periods, we performed χ analyses. For each subgroup, we calculated relative risk (RR). RESULTS: The number of national and state background checks for firearms purchases increased in the postlaw period (national and state p < 0.001); that increase was proportionately reflected in a relative increase in state firearm purchase in the postlaw period (1.50% prelaw vs. 1.59% postlaw, p < 0.001). Overall, victims of events potentially involving guns had an 11% increased risk of being injured or killed by a firearm (p = 0.036) The proportion of iGRIDs to overall city violent crime remained the same during the two periods (9.74% prelaw vs. 10.36% postlaw; RR, 1.06; 95% confidence interval, 0.96-1.17). However, in the postlaw period, the proportion of gun-related homicides increased by 27% after SB-1108 (RR, 1.27; 95% confidence interval, 1.02-1.58). CONCLUSION: Both nationally and statewide, firearm purchases increased after the passage of SB-1108. Although the proportion of iGRIDs to overall city violent crime remained the same, the proportion of gun-related homicides increased. Liberalization of gun access is associated with an increase in fatalities from guns. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Modified Veress needle decompression of tension pneumothorax: a randomized crossover animal study.

BACKGROUND: The current prehospital standard of care using a large bore intravenous catheter for tension pneumothorax (tPTX) decompression is associated with a high failure rate. We developed a modified Veress needle (mVN) for this condition. The purpose of this study was to evaluate the effectiveness and safety of the mVN as compared with a 14-gauge needle thoracostomy (NT) in a swine tPTX model. METHODS: tPTX was created in 16 adult swine via thoracic CO2 insufflation to 15 mm Hg. After tension physiology was achieved, defined as a 50% reduction of cardiac output, the swine were randomized to undergo either mVN or NT decompression. Failure to restore 80% baseline systolic blood pressure within 5 minutes resulted in crossover to the alternate device. The success rate of each device, death, and need for crossover were analyzed using χ. RESULTS: Forty-three tension events were created in 16 swine (24 mVN, 19 NT) at 15 mm Hg of intrathoracic pressure with a mean CO2 volume of 3.8 L. tPTX resulted in a 48% decline of systolic blood pressure from baseline and 73% decline of cardiac output, and 42% had equalization of central venous pressure with pulmonary capillary wedge pressure. All tension events randomized to mVN were successfully rescued within a mean (SD) of 70 (86) seconds. NT resulted in four successful decompressions (21%) within a mean (SD) of 157 (96) seconds. Four swine (21%) died within 5 minutes of NT decompression. The persistent tension events where the swine survived past 5 minutes (11 of 19 NTs) underwent crossover mVN decompression, yielding 100% rescue. Neither the mVN nor the NT was associated with inadvertent injuries to the viscera. CONCLUSION: Thoracic insufflation produced a reliable and highly reproducible model of tPTX. The mVN is vastly superior to NT for effective and safe tPTX decompression and physiologic recovery. Further research should be invested in the mVN for device refinement and replacement of NT in the field.