The prevalence of early contained vascular injury of spleen.

Contained vascular injuries (CVI) of spleen include pseudoaneurysms (PSA) and arterio-venous fistulae (AV-fistulae), and their reported prevalence varies. Our purpose was to assess the prevalence of early splenic CVI seen on admission CT in patients with splenic trauma admitted to a single level 1 trauma center in 2013-2021, and its detection in different CT protocols. A retrospective, single-center longitudinal cohort study. Nine-year data (2013-2021) of all patients with suspected or manifest abdominal trauma were retrieved. All patients, > 15 years with an ICD code for splenic trauma (S36.0XX) were included. CT and angiographic examinations were identified. Reports and images were reviewed. Splenic CVI CT criterion was a focal collection of vascular contrast that decreases in attenuation with delayed imaging. Number of CVIs and treatment was based on medical records and/or available angioembolization data. Of 2805 patients with abdominal trauma, 313 patients (313/2805; 11.2%) fulfilled the study entry criteria. 256 patients (256/313; 81.8%) had a CT examination. Sixteen patients had splenectomy before CT, and the final study group included 240 patients (240/313; 76.7%). Median New Injury Severity Score (NISS) was 27 and 87.5% of patients had NISS > 15. Splenic CVI was found in 20 patients, which yields a prevalence of 8.3% (20/240; 95% CI 5.2-12.6%). In those cases with both late arterial and venous phase images available, CVI was seen in 14.5% of cases (18/124, 95% CI 8.6-22.0%). None of the patients with CVI died within 30 days of the injury. The prevalence of early splenic CVI in patients with a splenic trauma was 8.3-14.5% (95% CI 5.2-22.0%). Our data suggests that both arterial and venous phase are needed for CT diagnosis. The 30-day outcome in terms of mortality was good.

Peroneal artery injury potential due to different syndesmosis screw placement options: a simulation study with lower extremity computed tomography angiography.

INTRODUCTION: The aim of this study is to assess the risk of peroneal artery injury of hardware placement at the fixation of syndesmotic injuries. MATERIALS AND METHODS: The lower extremity computed tomography angiography was used to design the study. The syndesmosis screw placement range was simulated every 0.5 cm, from 0.5 to 5 cm proximal to the ankle joint. The screw axes were drawn as 20°, 30° or individual angle according to the femoral epicondylar axis. The proximity between the screw axis and the peroneal artery was measured in millimeters. Potential peroneal artery injury was noted if the distance between the peroneal artery to the axis of the simulated screw was within the outer shaft radius of the simulated screw. The Pearson chi-square test was used and a p-value < 0.05 was considered significant. RESULTS: The potential for injury to the peroneal artery increased as the syndesmosis screw level rose proximally from the ankle joint level or as the diameter of the syndesmosis screw increasds. In terms of syndesmosis screw trajection, the lowest risk of injury was observed with the syndesmosis screw angle of 20°. Simulations with a screw diameter of 3.5 mm exhibited the least potential for peroneal artery injury. CONCLUSION: Thanks to this radiological anatomy simulation study, we believe that we have increased the awareness of the peroneal artery potential in syndesmosis screw application. Each syndesmosis screw placement option may have different potential for injury to the peroneal artery. To decrease the peroneal artery injury potential, we recommend the followings. If individual syndesmosis screw angle trajection can be measured, place the screw 1.5 cm proximal to the ankle joint using a 3.5 mm screw shaft. If not, fix it with 30° trajection regardless of the screw diameter at the same level. If the most important issue is the peroneal artery circulation, use the screw level up to 1 cm proximal to the ankle joint regardless of the screw angle trajection and screw diameter.

Understanding large vessel perforation requiring treatment with covered stent implantation: A case series.

Large vessel perforation during coronary intervention is a rare but potentially fatal complication, often requiring implantation of a covered stent for resolution. While technology is improving, the long-term patency of covered stents is less than drug-eluting stents, and implantation of covered stents should be used sparingly. Large vessel perforations are complex and often the perforation inflow is not located at the site of extravasation seen on angiography. This can lead to geographic miss when implanting covered stents and necessitate the implantation of additional covered stents which increases the risk for short- and long-term complications. We present a case series to further investigate the anatomy and mechanism of large vessel perforations and guidance on effective covered stent implantation.

A 12-year experience in the management of blunt thoracic aortic injury in Otautahi Christchurch.

BACKGROUND: Blunt thoracic aortic injury (BTAI) is associated with a high mortality and is the second most common cause of death from trauma. The approach to major trauma, imaging technology and advancement in endovascular therapy have revolutionised the management of BTAI. Endovascular therapy has now become the gold standard technique replacing surgery with its high mortality and morbidity in unstable patients. We aim to assess the outcomes following management of BTAI. METHOD: This is a retrospective study of all patients with BTAI between 1 January 2010 and 1 January 2022. Data were obtained from electronic health records. The grading of BTAI severity was done based on the Society of Vascular Surgery (SVS) Criteria. RESULTS: Fifty patients were included in the study analysis. The most common cause of BTAI was due to high-speed motor vehicle accidents (MVA) (36 patients, 72%). Grade 1 and grade 3 BTAI injuries were mostly encountered in 40% and 30% of the study cohort, respectively. Twenty-three patients (46%) underwent thoracic endovascular aortic repair (TEVAR). There was no secondary aortic re-intervention, conversion to open surgery or aortic-related deaths at 30 days or at most recent follow-up. CONCLUSION: Management of BTAI in our centre compares well with currently published studies. Long-term studies are warranted to guide clinicians in areas of controversy in BTAI management.

CT findings of inferior vena cava trauma according to the level of injury: a retrospective analysis of 19 cases in a single trauma centre.

AIM: To analyse the clinicoradiological characteristics of traumatic inferior vena cava (IVC) injury level on preoperative computed tomography (CT). MATERIALS AND METHODS: This retrospective study evaluated patients from a single trauma centre treated for traumatic IVC injury between January 2014 and January 2021. Data on demographics, mechanism of injury, Injury Severity Score, radiological findings on CT and angiography, IVC injury level in surgical findings, complications, and clinical outcomes were collected. RESULTS: During the 8-year study period, 36 patients presented with traumatic IVC injury: 19 underwent preoperative CT with 17 (89%) blunt and two (11%) penetrating injuries. The most common primary CT sign was contour abnormality (53%, n=10), followed by intraluminal flap and active extravasation (21%, n=4). Among the secondary signs, hepatic laceration (53%, n=10) and retroperitoneal haemorrhage (53%, n=10) were the most common. Frequencies of primary and secondary signs were higher in the infrarenal and suprarenal than in the retrohepatic vena cava injuries. Diagnostic capability of preoperative CT for IVC injury differed according to the IVC level. The detection rate was the highest for an infrarenal vena cava injury at 100% (n=4), followed by that for a suprarenal, suprahepatic, and retrohepatic vena cava injuries at 75% (n=3), 43% (n=3), and 25% (n=1), respectively. CONCLUSION: CT findings of traumatic IVC injuries may vary depending on the mechanism and anatomical site of injury. Familiarity with IVC injury imaging features may help in diagnosis and surgical treatment planning.

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.

Pediatric Vascular Surgery: A Review of Cases from a Dedicated Pediatric Vascular Surgery Clinic.

BACKGROUND: The experience in pediatric vascular diseases is limited in the United Kingdom and worldwide due to their rarity and variations in practice. We looked at types of cases presenting to a dedicated pediatric vascular clinic. METHODS: Medical records of children seen in a dedicated pediatric vascular clinic at a tertiary referral service between 2016 and 2022 were reviewed. These patients were either seen for the first time in that clinic or had their appointments as a follow-up after inpatient review or intervention while being under the care of pediatric teams in local hospitals. RESULTS: Fifty-five patients (34 males) were seen aged between 4 months and 17 years (mean 9.5 years). Common presentations were limb length discrepancy secondary to iatrogenic arterial occlusion, follow-up after bypass for trauma, lower limb swelling or discoloration, and varicose veins. Operative procedures included lower limb bypass, angioplasty, ligation of aneurysms, and varicose vein surgery. CONCLUSIONS: Pediatric vascular conditions are uncommon and therefore most vascular surgeons and trainees will have little exposure to such cases. Intervention is needed for arterial injury secondary to penetrating or iatrogenic trauma. A national registry is required for these rare cases to gain prospective data that can help build up more evidence for educational purposes and to establish guidelines.

Emergency Endovascular Repair of Thoracic Aorta Via a Percutaneous Popliteal Approach Following an Iatrogenic Injury.

Iatrogenic arterial injuries are rare but well-recognised complications of spinal surgery. This paper presents a case of an iatrogenic arterial injury during a total en bloc spondylectomy resulting in significant haemorrhage and the patient's haemodynamic instability. The devastating complication was successfully treated with an emergency thoracic endovascular aortic repair via a percutaneous popliteal approach, while the patient remained in prone position. The patient had an uneventful recovery with no subsequent arterial injury or pseudoaneurysm to the access vessel.

Vascular imaging immediately after tourniquet removal does not increase vasospasm risk.

BACKGROUND: Prehospital tourniquet use is now standard in trauma patients with diagnosed or suspected extremity vascular injuries. Tourniquet-related vasospasm is an understudied phenomenon that may confound management by causing erroneous arterial pressure indices (APIs) and abnormalities on computed tomography angiography (CTA) that do not reflect true arterial injuries. We hypothesized that shorter intervals between tourniquet removal and CTA imaging and longer total tourniquet times would be correlated with a higher likelihood of false positive CTA. MATERIALS AND METHODS: We performed a single-institution retrospective cohort study of patients presenting to a busy, urban Level 1 Trauma Center with prehospital tourniquets from 2019 to 2021. Patients who presented with a tourniquet disengaged upon arrival or who died prior to admission to the Trauma Unit were excluded. Tourniquet duration, time between tourniquet removal and CTA imaging (CTA interval), CTA findings, and management of extremity arterial injuries were extracted. The proportion of false positive injuries on CTA was assessed for correlation with increasing time interval from tourniquet removal to CTA imaging and correlation with increasing total tourniquet time using multivariable logistic regression. RESULTS: 251 patients were identified with prehospital tourniquets. 127 underwent CTA of the affected extremity, 96 patients had an abnormal CTA finding, and 57 (45% of total CTA patients) had false positive arterial injuries on imaging. Using multivariable logistic regression, neither the CTA interval nor the tourniquet duration was associated with false positive CTA injuries. Female sex was associated with false positive injuries on CTA (OR 2.91, 95% CI: 1.01 - 8.39). Vasospasm was cited as a possible explanation by radiologists in 40% of false positive CTA reports. CONCLUSIONS: Arterial vasospasm is a frequent finding on CTA after tourniquet use for extremity trauma, but concerns regarding tourniquet-related vasospasm should not alter trauma patient management. Neither the duration of tourniquet application nor the time interval since removal is associated with decreased CTA accuracy, and any delay in imaging does not appear to reduce the likelihood of vasospasm. These findings are important for supporting expedited care of trauma patients with severe extremity injuries.

Incidence and characteristics of vascular trauma at a level 2 trauma center.

OBJECTIVE: Despite the significant number of trauma patients treated at level 2 trauma centers (L2TCs) in the United States, most of the literature describing vascular trauma is from level 1 trauma centers (L1TCs). Currently, trauma center designation criteria do not require vascular surgery as a necessary component service. METHODS: A retrospective chart review was performed for all trauma patients with a vascular surgery consultation seen at our L2TC between 2013 and 2018. Patient demographics, injury characteristics, and outcomes were collected and analyzed with descriptive statistics. RESULTS: Of the 3062 trauma patients evaluated at our L2TC, 110 (3.6%) had a vascular surgery consultation. Operative intervention was performed in 35.2% of consults, and 1.0% of all trauma patients had a vascular intervention. Average age was 57 years, and the majority were male (n = 75; 68.2%). Mean Injury Severity Score was 12.0 ± 9.6, and blunt injury (n = 77; 87.5%) was more common than penetrating (n = 11; 12.5%). The most common location of injury was the lower extremity (n = 23; 74.2%), followed by upper extremity (n = 3; 9.7%), chest (n = 2; 6.5%), neck (n = 2; 6.5%), and pelvis (n = 1; 3.2%). Endovascular interventions were performed by the vascular surgery service in 67.7% (n = 21) of all injuries. There was one amputation (3.2%) and one postoperative mortality (3.2%). CONCLUSIONS: At our L2TC, postoperative morbidity and mortality rates at 30 days were substantially lower compared with previously reported data. However, mean injury severity score and the incidence of penetrating and polytrauma were also lower at our institution. Most patients were managed nonoperatively, but when they did require an operation, endovascular therapies were more commonly implemented. Vascular surgery should be considered an integral service in trauma level designation, and there is a need for further investigation of these outcomes in L2TCs.

2nd Window NIR Imaging of Radiation Injury Mitigation Provided by Reduced Notch-Dll4 Expression on Vasculature.

PURPOSE: Vascular endothelium plays a central role in the pathogenesis of acute and chronic radiation injuries, yet the mechanisms which promote sustained endothelial dysfunction and contribute to late responding organ failure are unclear. We employed 2nd window (> 1100 nm emission) Near-Infrared (NIR) imaging using indocyanine green (ICG) to track and define the role of the notch ligand Delta-like ligand 4 (Dll4) in mediating vascular injury in two late-responding radiosensitive organs: the lung and kidney. PROCEDURES: Consomic strains of female Salt Sensitive or SS (Dll4-high) and SS with 3rd chromosome inherited from Brown Norway, SS.BN3 (Dll4-low) rats at ages 11-12 weeks were used to demonstrate the impact of reduced Dll4 expression on long-term vascular integrity, renal function, and survival following high-dose 13 Gy partial body irradiation at 42- and 90 days post-radiation. 2nd window dynamic NIR fluorescence imaging with ICG was analyzed with physiology-based pharmacokinetic modeling and confirmed with assays of endothelial Dll4 expression to assess the role of endogenous Dll4 expression on radiation injury protection. RESULTS: We show that SS.BN3 (Dll4-low) rats are relatively protected from vascular permeability disruption compared to the SS (Dll4-high) strain. We further demonstrated that SS.BN3 (Dll4-low) rats have reduced radiation induced loss of CD31+ vascular endothelial cells, and increased Dll4 vascular expression is correlated with vascular dysfunction. CONCLUSIONS: Together, these data suggest Dll4 plays a key role in pathogenesis of radiation-induced vascular injury to the lung and kidney.

Development and Validation of a Risk Prediction Tool for In-hospital Mortality After Thoracic Endovascular Repair in Patients with Blunt Thoracic Aortic Injury Using the Aortic Trauma Foundation Registry.

BACKGROUND: The objective of our present effort was to use an international blunt thoracic aortic injury (BTAI) registry to create a prediction model identifying important preoperative and intraoperative factors associated with postoperative mortality, and to develop and validate a simple risk prediction tool that could assist with patient selection and risk stratification in this patient population. METHODS: For the purpose of the present study, all patients undergoing thoracic endovascular aortic repair (TEVAR) for BTAI and registered in the Aortic Trauma Foundation (ATF) database from January 2016 as of June 2022 were identified. Patients undergoing medical management or open repair were excluded. The primary outcome was binary in-hospital all-cause mortality. Two predictive models were generated: a preoperative model (i.e. only including variables before TEVAR or intention-to-treat) and a full model (i.e. also including variables after TEVAR or per-protocol). RESULTS: Out of a total of 944 cases included in the ATF registry until June 2022, 448 underwent TEVAR and were included in the study population. TEVAR for BTAI was associated with an 8.5% in-hospital all-cause mortality in the ATF dataset. These study subjects were subsequently divided using 3:1 random sampling in a derivation cohort (336; 75.0%) and a validation cohort (112; 25.0%). The median age was 38 years, and the majority of patients were male (350; 78%). A total of 38 variables were included in the final analysis. Of these, 17 variables were considered in the preoperative model, 9 variables were integrated in the full model, and 12 variables were excluded owing to either extremely low variance or strong correlation with other variables. The calibration graphs showed how both models from the ATF dataset tended to underestimate risk, mainly in intermediate-risk cases. The discriminative capacity was moderate in all models; the best performing model was the full model from the ATF dataset, as evident from both the Receiver Operating Characteristic curve (Area Under the Curve 0.84; 95% CI 0.74-0.91) and from the density graph. CONCLUSIONS: In this study, we developed and validated a contemporary risk prediction model, which incorporates several preoperative and postoperative variables and is strongly predictive of early mortality. While this model can reasonably predict in-hospital all-cause mortality, thereby assisting physicians with risk-stratification as well as inform patients and their caregivers, its intrinsic limitations must be taken into account and it should only be considered an adjunctive tool that may complement clinical judgment and shared decision-making.

Lower Extremity Vascular Injury in the Pediatric Trauma Patient: Management and Outcomes at an Adult Level I Trauma Center.

BACKGROUND: Traumatic vascular injuries of the lower extremity in the pediatric population are uncommon but can result in significant morbidity. The objective of this study is to demonstrate our experience with these injuries by describing patterns of traumatic vascular injury, the initial management, and data regarding early outcomes. METHODS: In total, 506 patients presented with lower extremity vascular injury between January 1, 2009 and January 1, 2021 to Grady Memorial Hospital, an urban, adult Level I trauma center in Atlanta, Georgia. Thirty-two of the 506 patients were aged less than 18 years and were evaluated for a total of 47 lower extremity vascular injuries. To fully elucidate the injury patterns and clinical course in this population, we examined patient demographics, mechanism of injury, type of vessel injured, surgical repair performed, and early outcomes and complications. RESULTS: The median (interquartile range) age was 16 (2) years (range, 3-17 years), and the majority were male (n = 29, 90.6%). Of the vascular injuries identified, 28 were arterial and 19 were venous. Of these injuries, 14 patients had combined arterial-venous injuries. The majority of injuries were the result of a penetrating injury (n = 28, 87.5%), and of these, all but 2 were attributed to gunshot wounds. Twenty-seven vascular interventions were performed by nonpediatric surgeons: 11 by trauma surgeons, 13 by vascular surgeons, 2 by orthopedic surgeons, and 1 by an interventional radiologist. Two patients required amputation: 1 during the index admission and 1 delayed at 3 months. Overall survival was 96.9%. CONCLUSIONS: Vascular injuries as the result of trauma at any age often require early intervention, and we believe that these injuries in the pediatric population can be safely managed in adult trauma centers with a multidisciplinary team composed of trauma, vascular, and orthopedic surgeons with the potential to decrease associated morbidity and mortality from these injuries.

Cross-Limb Vascular Shunting for Traumatic Popliteal Artery Injury.

BACKGROUND: Popliteal artery injury (PAI) is a challenging trauma that requires prompt and accurate treatment since the probability of lower-limb amputation increases with the ischemic time. Intravascular shunting and cross-limb vascular shunting (CLS) are used as temporary vascular shunting (TVS) methods to shorten the ischemic time for limb vascular injury. CLS involves sending blood from an artery in a healthy body part to a peripheral vessel in an injured part to immediately resume blood flow to the injured limb. For closed injuries including PAI, CLS may be performed without exploring and identifying the arterial stumps and it enables early reperfusion to the ischemic limb. We report the case series of traumatic PAI treated using CLS and verify the usefulness of CLS. METHODS: All patients with traumatic PAI treated with CLS at our institution between August 2013 and December 2021 were included. Demographic and clinical patient characteristics were extracted from the medical records. Comorbid injuries, severity of acute limb ischemia based on the Rutherford grading scale, time from injury to reperfusion by CLS, time from injury to completion of artery, and the use of fasciotomy were investigated. As outcomes, we investigated the presence or absence of lower extremity amputation during the course of treatment. RESULTS: We used CLS as treatment for 5 cases with traumatic PAI. Based on the Rutherford grading scale for acute limb ischemia, there were one limb with grade 2B and 4 with grade 3. Amputation of the lower extremities was avoided except for 1 extremity in which arterial reconstruction was not achieved due to unexplained cardiac arrest during surgery. CONCLUSIONS: CLS enables early reperfusion of the injured limb and is effective as a TVS method for traumatic PAI with severe ischemia or soft tissue damage.

Axillary Artery Injuries Associated With Proximal Humerus Fractures: A Literature Review and a Proposal of a Novel Multidisciplinary Surgical Approach.

INTRODUCTION: Proximal humerus fractures (PHF) are common injuries that can lead to axillary artery injury, which carries the risk of not being identified during initial assessment. The aim of this study was to describe the management of suspected axillary artery injury associated with PHF according to our experience and to describe a new multidisciplinary surgical approach. METHODS: This was a single-center retrospective study. A database was created for patients admitted for PHF to the emergency department of the Hospital of Cannes between October 2017 and October 2019. Patients admitted with PHF associated with suspected ipsilateral upper limb ischemia, and/or massive diaphysis displacement, and/or upper limb ipsilateral neurological deficits were included in this study. RESULTS: In total, 301 patients diagnosed with PHF were admitted within these periods. Among these patients, 12 presented with suspected axillary artery lesions, of whom, 6 were included in the present study and treated according to our new approach. A description of these 6 cases, along with an extensive literature review is presented. CONCLUSION: Based on our experience, the endovascular approach proposed for the management of axillary artery injury associated with proximal humerus fractures is effective, feasible and reproducible.

Vascular Reconstruction and Limb Loss in Military Tibial Artery Injuries.

BACKGROUND: Selective operative management of injuries to the tibial arteries is controversial, with the necessity of revascularization in the face of multiple tibial arteries debated. Tibial artery injuries are frequently encountered in military trauma, but revascularization practices and outcomes are poorly defined. We aimed to investigate associations between the number of injured vessels and reconstruction and limb loss rates in military casualties with tibial arterial trauma. METHODS: A US military database of lower extremity vascular injuries from Iraq and Afghanistan (2004-2012) was queried for limbs sustaining at least 1 tibial artery injury. Injury, intervention characteristics, and limb outcomes were analyzed by the number of tibial arteries injured (1, T1; 2, T2; 3, T3). RESULTS: Two hundred twenty one limbs were included (194 T1, 22 T2, 5 T3). The proportions with concomitant venous, orthopedic, nerve, or proximal arterial injuries were similar between groups. Arterial reconstruction (versus ligation) was performed in 29% of T1, 63% of T2, and universally in T3 limbs (P < 0.001). Arterial reconstruction was via vein graft (versus localized repair) in 62% of T1, 54% of T2, and 80% of T3 (P = 0.59). T3 received greater blood transfusion volume (P = 0.02), and fasciotomy was used universally (versus 34% T1 and 14% T2, P = 0.05). Amputation rates were 23% for T1, 26% for T2, and 60% for T3 (P = 0.16), and amputation was not significantly predicted by arterial ligation in T1 (P = 0.08) or T2 (P = 0.34) limbs. Limb infection was more common in T3 (80%) than in T1 (25%) or T2 (32%, P = 0.02), but other limb complication rates were similar. CONCLUSIONS: In this series of military lower extremity injuries, an increasing number of tibial arteries injured was associated with the increasing use of arterial reconstruction. Limbs with all 3 tibial arteries injured had high rates of complex vascular reconstruction and eventual amputation. Limb loss was not predicted by arterial ligation in 1-vessel and 2-vessel injuries, suggesting that selective reconstruction in these cases is advisable.

Indications for computed tomography angiography in limb trauma.

INTRODUCTION: Computed tomography angiograms (CTAs) are useful in detecting vascular injury. There is a lack of consensus regarding the indications of CTAs in limb trauma, leading to overutilisation of CTAs in some centres and exposing patients to unnecessary harm. Thus, the aim of this study is to define the appropriate indications for CTAs in limb trauma. METHODS: This is a retrospective cohort study of consecutive CTAs performed in a tertiary hospital from January to December 2022. Demographic and clinical factors were collected from the patients' charts including physical examination findings and arterial pressure index (API) measurements. Physical examination findings include hard signs (e.g. absent pulse) or soft signs (e.g. non-expanding haematoma). These data were analysed to detect correlation with vascular injury on the patient's CTA. RESULTS: Forty-nine CTAs were included, of which 10 (20.4%) found vascular injury. Hard signs (P < 0.001) and an API <0.9 (P = 0.02) were significantly correlated with vascular injury. Hard signs had a sensitivity of 90% and specificity of 82%, whereas APIs had a specificity and sensitivity of 100%. Soft signs were not correlated with vascular injury due to poor specificity but had a sensitivity of 100%. Knee dislocations were not associated with vascular injury (P = 0.5). CONCLUSION: This small study suggests that CTAs are indicated if there are hard signs of vascular compromise or an API <0.9, provided the patient is haemodynamically stable. The presence of soft signs can help identify which patients should receive an API measurement. CTAs may not be routinely indicated in knee dislocations.

Trust but Verify? Utility of Intraoperative Angiography After Revascularization for Vascular Trauma.

BACKGROUND: Trauma surgical dogma teaches that patients should have intraoperative angiography (IA) if the surgeon cannot identify a pulse in the injured extremity following a vascular repair. This study was undertaken to assess the utility of IA in trauma patients who underwent open brachial or femoral artery revascularization. METHODS: Retrospective analysis of the Prospective Observational Vascular Injury Trial (PROOVIT) database from 2013 to 2021 evaluated patients >15 years with penetrating or blunt injuries requiring operative intervention of the brachial, superficial femoral, or common femoral arteries. Prospective Observational Vascular Injury Trial data evaluated included documented pulse in the injured extremity at revascularization completion, adjunctive IA, immediate revision, and vascular reintervention during the hospitalization. RESULTS: Of the 5057 patients with vascular injury, 185 patients met our inclusion criteria. The majority were male (86.5%) with a median age, injury severity score, and systolic blood pressure of 29, 12, and 117, respectively. Of the study patients, 39% underwent IA, 14% had immediate revision, and 8% required vascular reoperation during their admission. Patients who underwent IA and with no documented palpable pulse after repair were significantly more likely to require immediate revision before leaving the operating room (22% vs 9%, P = .013) and were not more likely to require reoperation, than those who did not undergo IA (7% vs 9%, P = .613). CONCLUSIONS: Intraoperative angiography is a valuable tool for surgeons for vascular extremity trauma and is associated with a greater rate of immediate revision. Familiarity with angiographic technique is essential for vascular trauma and should be a focal point of training.

The Order of Operative Repair Does Not Influence Outcomes in Patients with Concomitant Popliteal Artery and Orthopedic Injuries.

BACKGROUND: The most challenging lower extremity traumatic injuries involve concomitant vascular and orthopedic injuries with amputation rates approaching 50%. Controversy exists as to how to prioritize the vascular and orthopedic repairs. We reviewed patients with popliteal artery and lower extremity orthopedic injuries to analyze the sequence of the vascular and orthopedic repairs on outcomes. METHODS: All adult patients with a diagnosis of concomitant popliteal artery and lower extremity fracture or dislocation were identified through a review of an institutional trauma registry performed at a level 1 trauma center from 2014 to 2019. Patient demographics, timing of presentation, injury severity score (ISS), surgical interventions, and limb outcome data were collected and examined. The sequence of operative repairs and factors influencing the operative order were analyzed. RESULTS: Twenty-nine patients were treated for popliteal artery injuries. Twelve of these 29 patients had concomitant popliteal artery and orthopedic fractures requiring surgical repair. Injury mechanisms included both blunt (50%, 6/12) and penetrating trauma (50%, 6/12); the majority involved femur fractures (58%, 7/12). Vascular repair included arterial bypass (75%, 9/12) or interposition grafts (25%, 3/12). Orthopedic repair included external fixation (83%, 10/12) and open reduction internal fixation (17%, 2/12). Vascular repair was performed first in 7/12 limbs (58%). Patients having vascular repair first had a trend toward lower blood pressure on arrival (P = 0.068). There was no significant difference in emergency department to operating room (OR) time, OR time, ISS, mangled extremity severity score, estimated blood loss, or blood transfusion for the sequence of operative repair. Fasciotomy was nearly ubiquitous, present in 11/12 patients (92%). There were no graft complications related to orthopedic manipulation, and there were no reported limb-length to graft-length discrepancies. Early limb salvage trended lower in the cohort with revascularization first (71% vs. 100%, P = 0.19). Of the remaining limbs available for follow-up, limb salvage at 4.25 years is 100%. CONCLUSIONS: In this small study of patients with concomitant lower extremity popliteal artery and orthopedic injuries, the order of operative repair does not appear to influence the success of revascularization.

Systematic Review and Meta-Analysis of Nonoperative Management for SVS Grade II Blunt Traumatic Aortic Injury.

BACKGROUND: Society for Vascular Surgery (SVS) grade II blunt traumatic aortic injury is defined as intramural hematoma with or without external contour abnormality. It is uncertain whether this aortic injury pattern should be treated with endovascular stent-grafting or nonoperative measures. Since the adoption of the SVS Guidelines on endovascular repair of blunt traumatic aortic injury, the practice pattern for management of grade II injuries has been heterogenous. The objective of the study was to report natural history outcomes of grade II blunt traumatic aortic injury. METHODS: A systematic review of published traumatic aortic injury studies was performed. Online database searches were current to November 2022. Eligible studies included data on aortic injuries that were both managed nonoperatively and classified according to the SVS 2011 Guidelines. Data points on all-cause mortality, aorta-related mortality and early aortic intervention were extracted and underwent meta-analysis. The methodology was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance. RESULTS: Thirteen studies were included in the final analysis with a total of 204 cases of SVS grade II blunt traumatic aortic injury treated nonoperatively. The outcomes rates were estimated at 10.4% (95% confidence interval [CI] 6.7%-14.9%) for all-cause mortality, 2.9% (95% CI 1.1%-5.7%) for aorta-related mortality, and 3.3% (95% CI 1.4%-6.2%) for early aortic intervention. The studies included in the analysis were of fair quality with a mean Downs and Black score 15 (±1.8). CONCLUSIONS: Grade II blunt traumatic aortic injury follows a relatively benign course with few instances of aortic-related mortality. Death in the setting of this injury pattern is more often attributable to sequelae of multisystem trauma and not directly related to aortic injury. The current data support nonoperative management and imaging surveillance for grade II blunt traumatic aortic injury instead of endovascular repair. Longer-term effects on the aorta at the site of injury are unknown.