Treatment Strategies And Outcomes Of Thoracic Aortic Blunt Injuries In Adults: A Systematic Review.

INTRODUCTION: Blunt thoracic aortic injuries (BTAI) once had mortality rates up to 32%, but the advent of thoracic endovascular aortic repair (TEVAR) has significantly improved outcomes. However, concerns persist regarding long-term devicerelated complications, device integrity in aging aortas, and the criteria for selecting patients for endovascular repair. We aimed to assess BTAI treatment strategies based on injury grade and their associated outcomes. METHODS: A systematic search of MedLine and Scopus databases was conducted to identify original articles published after 2013, which provided information on injury characteristics, outcomes, secondary effects, and reinterventions following BTAI. We classified aortic injuries following the SVS Clinical Practice Guidelines. RESULTS: We included 28 studies involving 1888 BTAI patients, including 5 prospective studies. Most patients were under 45 years old (86.4%), and grade III injuries were the most common (901 patients), followed by grades I and II (307 and 291 patients, respectively). TEVAR was performed in 1458 patients, mainly with grade III and IV injuries (1040 patients). Approximately half of the grade I injuries (153 of 307) were treated with TEVAR. Thirty-day mortality rate was 11.2%, primarily due to associated injuries. Aortic-related deaths were reported in 21 studies, with an overall rate of 2.2%, but none occurred beyond the first 30 days. Partial or complete coverage of the left subclavian artery was performed in 522 patients, with 27.9% requiring immediate or delayed revascularization. Aortic reintervention rates were relatively low (3.9%). CONCLUSION: TEVAR effectively treats BTAI grades III and IV, with potential benefit for some grade II injuries with more aggressive early intervention. Despite SVS guidelines suggesting conservative management for grade I injuries, there is a substantial rate of intervention with positive outcomes and low mortality. Long-term follow-up data, extending up to almost 20 years, reveal the durability of grafts, aortic remodeling, and minimal reintervention and complications.

Delayed femoral artery injury caused by heterotopic ossification: a rare case report and review of the literature.

BACKGROUND: Arterial injury caused by heterotopic ossification (HO) following fractures is rarely reported, yet it can have catastrophic consequences. This case report presents a unique instance of femoral artery injury and hematoma organization, occurring a decade after intramedullary nail fixation for a femoral shaft fracture complicated by HO. CASE PRESENTATION: A 56-year-old male presented with right femoral artery injury and organized hematoma, a decade after suffering bilateral femoral shaft fractures with mild head injury in a traffic accident. He had received intramedullary nailing for the right femoral shaft fracture and plate fixation for the left side in a local hospital. Physical examination revealed two firm, palpable masses with clear boundaries, limited mobility, and no tenderness. Peripheral arterial pulses were intact. Radiography demonstrated satisfactory fracture healing, while a continuous high-density shadow was evident along the inner and posterior aspect of the right thigh. Computed tomography angiography identified a large mixed-density mass (16.8 × 14.8 × 20.7 cm) on the right thigh's medial side, featuring central calcification and multiple internal calcifications. The right deep femoral artery coursed within this mass, with a smaller lesion noted on the posterior thigh. Surgical consultation with a vascular surgeon led to planned intervention. The smaller mass was completely excised, but the larger one partially, as it encased the femoral artery. The inability to remove all HO was due to excessive bleeding. Postoperatively, the patient experienced no complications, and one-year follow-up revealed a favorable recovery with restoration of full right lower limb mobility. CONCLUSION: This case underscores the potential gravity of vascular injury associated with heterotopic ossification. Surgeons should remain vigilant regarding the risk of vascular injury during HO excision.

Management of Suspected Peripheral Vascular Injuries in Orthopedic Trauma.

OBJECTIVE: In orthopedic trauma, identification of extremity trauma combined with vascular injury is challenging. Missed diagnosis may result in amputation or even death. The purpose of this study was to investigate whether physical examination combined with handheld vascular ultrasound Doppler examination could be an effective method of screening for peripheral vascular injury and to explore the characteristics of vascular injuries in orthopedic trauma patients. METHODS: Retrospective analysis of patients in the emergency department of orthopedic trauma in our hospital from January 2022 to October 2023. Physical examination combined with handheld vascular ultrasound Doppler examination was used as a screening method for suspected vascular injuries. Patients with suspected vascular injury would undergo further angiography and receive multidisciplinary treatment. Angiography was used as the gold standard for diagnosing vascular injuries. Patient demographics, mechanism of injury, location and type of injury, angiographic results, surgical notes, and early treatment outcome data were recorded. RESULTS: A total of 55 cases (58 limb injuries) with suspected vascular injury were ultimately included. Angiography revealed that 53 cases (55 limbs, positive rate 94.8%) were considered to have confirmed vascular injuries. Forty-three were male (81.1%) and 10 were female (18.9%), with mean age 44.1 ± 16.6 years. The main mechanism of injury was traffic accident (30, 56.7%). Most common site of vascular injuries was knee joint (30/55, 54.5%), and popliteal artery (23, 47.9%) was the most commonly injured blood vessel. After multidisciplinary collaborative treatment, overall patient mortality was 3.8% (2/53), and limb survival rate among surviving patients was 81.1% (43/53) in our study. CONCLUSION: In orthopedic trauma, "Hard signs" and "soft signs" combined with handheld vascular ultrasound Doppler examination were effective ways to screen for suspected vascular injuries. Most limbs had associated fractures or dislocations at the site of vascular injury. Collaboration of vascular surgery, microsurgery and orthopedic trauma may help improve patients' prognosis.

Damage-control vascular surgery in Canada: supporting surgeons and teams.

SummaryIn Canada, trauma patients often present initially to non-trauma hospitals without vascular surgeons on site. Local surgeons need skills and support for damage-control vascular surgery. Canadian training programs in general surgery should equip trainees with skills in this area, including resuscitation, identification of vascular injury, hemorrhage control, and temporizing measures (e.g., shunts, ligation). Caring for trauma patients is a multidisciplinary endeavour; understanding local/regional skill sets and from whom to seek help is vital. Opportunities for skills maintenance should also be encouraged for surgeons practising at sites where acutely injured patients present.

Our experience with blast and gunshot induced traumatic vascular injuries at Somalia's major vascular referral center.

Blast and gunshot-induced penetrating traumatic vascular injuries represent a significant portion of patients with vascular trauma in countries where there are higher rates of war-related violence. These injuries are especially challenging in resource-limited countries due to early diagnosis and transfer delays. This report aimed to present our experience regarding the surgical management and outcome of such injuries at a major referral vascular surgery centre in the country. A retrospective descriptive review of 326 patients with blast and gunshot-induced penetrating traumatic vascular injuries managed during a five-year period between April 2018 and April 2023. The demographics, mechanism of injury, type of vascular injury, Anatomical location, time to the operation, length of hospital stay, amount of blood products given, concomitant neuroskeletal injuries, development of Vascular injury associated acute kidney injury, surgical procedures performed and patient outcome were reviewed. In this study, 326 patients with 445 vascular injuries fulfilled the inclusion criteria. Most of the patients were male 92.3%, and the mean age was 28.3 ± 9.9 years. The gunshot mechanism of vascular injury was implicated in 76.1% of the injuries, and explosive-induced injury was 78 (23.9%). 193 (59.2%) of the patients had isolated arterial injuries, 117 (35.9%) patients had combined arterial and venous injuries while 18 (4.9%) patients had isolated venous injuries. The most commonly injured arteries were the femoral artery, followed by Brachial and popliteal artery injuries (26.1%, 23.5% and 19.4%, respectively). The median time to revascularization was 8.8 ± 8.7 h. 46.8% of the patients had Concomitant fractures, while 26.5% had Concomitant nerve injuries. Only three patients had temporary non-heparin-bound shunts during their arrival. The most common surgical intervention in arterial injuries was reversed saphenous vein graft 46.1%. The mortality was 5.8% and 7.7% of the patients needed secondary amputation. The majority of wartime arterial injuries are a result of Blast and gunshot vascular injuries. Frequent need for autologous vein grafts should be considered to manage such injuries. Results are encouraging despite delays in intervention; therefore, all viable limbs should be revascularized, keeping in mind the long-term functionality of the limb.

The role of body mass index in high- and low-velocity trauma causing knee injury associated with popliteal artery lesions.

BACKGROUND: Among arterial traumas, osteoarticular traumas are particularly dangerous, and those involving the popliteal artery are associated with a high amputation rate. Despite representing a minority of arterial traumas, with an incidence that varies considerably by population and geographic location, traumatic lesions of the popliteal artery are challenging. This study aimed to verify the impact of body mass index (BMI) on arterial trauma damage and patient outcomes. METHODS: Data were retrospectively collected from the electronic medical reports of all patients with osteoarticular and vascular associated lesions treated in the emergency operating room at our institution between 1 January 2005 and 1 May 2022. Forty-one patients presented with lower limb arterial trauma (43.2%); popliteal artery lesions occurred in 11 of these patients (26.8%), who were eligible for inclusion in the study. The lesion mechanism was dislocation by high-velocity trauma in 9 patients and dislocation by low-velocity trauma in 3 patients. All 7 males (63.6%) experienced high-velocity trauma, and 2 of the 3 females experienced low-velocity trauma. Only one patient had an isolated popliteal artery lesion associated with fractures in the leg or the contralateral limb. Patients with low-velocity trauma were older than 54 years, while those with high-velocity trauma were aged 22 to 71 years. RESULTS: In 10/11 patients (90.9%), revascularization was performed after osteoarticular stabilization and reduction of the dislocation or fracture. Intraoperative angiography was selectively used. Two patients required above-the-knee amputation after the procedure: one due to infection of the surgical access point and the other due to severe soft tissue injury. One patient died during hospitalization due to trauma-related complications and comorbidities. CONCLUSIONS: High-velocity trauma and low-velocity trauma in patients with a body mass index > 35 kg/m2 and knee lesions are associated with popliteal artery lesions. Revascularization success is not associated with high- or low-velocity trauma.

Association of rurality with short-term outcomes of peripheral vascular trauma.

BACKGROUND: Peripheral vascular trauma is a major contributing factor to long-term disability and mortality among patients with traumatic injuries. However, an analysis focusing on individuals at a high risk of experiencing limb loss due to rural and urban peripheral vascular trauma is lacking. METHOD: This was a retrospective analysis of the 2016 to 2020 Nationwide Readmissions Database. Patients (≥18 years) undergoing open or endovascular procedures after admission for peripheral vascular trauma were identified using the 2016 to 2020 Nationwide Readmissions Database. Patients from rural regions were considered Rural, whereas the remainder comprised Urban. The primary outcome of the study was primary amputation. Multivariable regression models were developed to evaluate rurality with outcomes of interest. RESULTS: Of 29,083 patients, 4,486 (15.6%) were Rural. Rural were older (41 [28-59] vs 37 [27-54] years, P < .001), with a similar distribution of female sex (23.0 vs 21.3%, P = .09) and transfers from other facilities (2.8 vs 2.5%, P = .34). After adjustment, Rural status was not associated with the odds of mortality (P = .82), with urban as reference. Rural status was, however, associated with greater odds of limb amputation (adjusted odds ratio 1.85, 95% confidence interval 1.47-2.32) and reduced index hospitalization cost by $7,100 (95% confidence interval $3,500-10,800). Additionally, compared to patients from urban locations, rurality was associated with similar odds of non-home discharge and 30-day readmission. Over the study period, the marginal effect of rurality on the risk-adjusted rates of amputation significantly increased (P < .001). CONCLUSION: Patients who undergo peripheral vascular trauma management in rural areas appear to increasingly exhibit a higher likelihood of amputation, with lower incremental costs and a lower risk of 30-day readmission. These findings underscore disparities in access to optimal trauma vascular care as well as limited resources in rural regions.

Management of an Iatrogenic Pulmonary Artery Rupture via Balloon Tamponade.

Pulmonary artery rupture is a rare complication of right heart catheterization characterized by a rapid clinical deterioration and high mortality rate. We present the case of an 89-year-old woman with severe symptomatic aortic stenosis who underwent cardiac catheterization prior to aortic valve replacement. The patient had acute cardiopulmonary deterioration due to pulmonary artery rupture at the time of right heart catheterization, that was successfully sealed by balloon tamponade.

Systematic review and meta-analysis of endovascular therapy versus open surgical repair for the traumatic lower extremity arterial injury.

OBJECTIVE: For traumatic lower extremity artery injury, it is unclear whether it is better to perform endovascular therapy (ET) or open surgical repair (OSR). This study aimed to compare the clinical outcomes of ET versus OSR for traumatic lower extremity artery injury. METHODS: The Medline, Embase, and Cochrane Databases were searched for studies. Cohort studies and case series reporting outcomes of ET or OSR were eligible for inclusion. Robins-I tool and an 18-item tool were used to assess the risk of bias. The primary outcome was amputation. The secondary outcomes included fasciotomy or compartment syndrome, mortality, length of stay and lower extremity nerve injury. We used the random effects model to calculate pooled estimates. RESULTS: A total of 32 studies with low or moderate risk of bias were included in the meta-analysis. The results showed that patients who underwent ET had a significantly decreased risk of major amputation (OR = 0.42, 95% CI 0.21-0.85; I2=34%) and fasciotomy or compartment syndrome (OR = 0.31, 95% CI 0.20-0.50, I2 = 14%) than patients who underwent OSR. No significant difference was observed between the two groups regarding all-cause mortality (OR = 1.11, 95% CI 0.75-1.64, I2 = 31%). Patients with ET repair had a shorter length of stay than patients with OSR repair (MD=-5.06, 95% CI -6.76 to -3.36, I2 = 65%). Intraoperative nerve injury was just reported in OSR patients with a pooled incidence of 15% (95% CI 6%-27%). CONCLUSION: Endovascular therapy may represent a better choice for patients with traumatic lower extremity arterial injury, because it can provide lower risks of amputation, fasciotomy or compartment syndrome, and nerve injury, as well as shorter length of stay.

Surgeon volume and outcomes following thoracic endovascular aortic repair for blunt thoracic aortic injury.

OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI) at high-volume hospitals has previously been associated with lower perioperative mortality, but the impact of annual surgeon volume on outcomes following TEVAR for BTAI remains unknown. METHODS: We analyzed Vascular Quality Initiative (VQI) data from patients with BTAI that underwent TEVAR between 2013 and 2023. Annual surgeon volumes were computed as the number of TEVARs (for any pathology) performed over a 1-year period preceding each procedure and were further categorized into quintiles. Surgeons in the first volume quintile were categorized as low volume (LV), the highest quintile as high volume (HV), and the middle three quintiles as medium volume (MV). TEVAR procedures performed by surgeons with less than 1-year enrollment in the VQI were excluded. Using multilevel logistic regression models, we evaluated associations between surgeon volume and perioperative outcomes, accounting for annual center volumes and adjusting for potential confounders, including aortic injury grade and severity of coexisting injuries. Multilevel models accounted for the nested clustering of patients and surgeons within the same center. Sensitivity analysis excluding patients with grade IV BTAI was performed. RESULTS: We studied 1321 patients who underwent TEVAR for BTAI (28% by LV surgeons [0-1 procedures per year], 52% by MV surgeons [2-8 procedures per year], 20% by HV surgeons [≥9 procedures per year]). With higher surgeon volume, TEVAR was delayed more (in <4 hours: LV: 68%, MV: 54%, HV: 46%; P < .001; elective (>24 hours): LV: 5.1%; MV: 8.9%: HV: 14%), heparin administered more (LV: 80%, MV: 81%, HV: 87%; P = .007), perioperative mortality appears lower (LV: 11%, MV: 7.3%, HV: 6.5%; P = .095), and ischemic/hemorrhagic stroke was lower (LV: 6.5%, MV: 3.6%, HV: 1.5%; P = .006). After adjustment, compared with LV surgeons, higher volume surgeons had lower odds of perioperative mortality (MV: 0.49; 95% confidence interval [CI], 0.25-0.97; P = .039; HV: 0.45; 95% CI, 0.16-1.22; P = .12; MV/HV: 0.50; 95% CI, 0.26-0.96; P = .038) and ischemic/hemorrhagic stroke (MV: 0.38; 95% CI, 0.18-0.81; P = .011; HV: 0.16; 95% CI, 0.04-0.61; P = .008). Sensitivity analysis found lower adjusted odds for perioperative mortality (although not significant) and ischemic/hemorrhagic stroke for higher volume surgeons. CONCLUSIONS: In patients undergoing TEVAR for BTAI, higher surgeon volume is independently associated with lower perioperative mortality and postoperative stroke, regardless of hospital volume. Future studies could elucidate if TEVAR for non-ruptured BTAI might be delayed and allow stabilization, heparinization, and involvement of a higher TEVAR volume surgeon.

Initial Outcomes of the Gore TAG Thoracic Branch Endoprosthesis for Endovascular Repair of Blunt Thoracic Aortic Injury.

BACKGROUND: Endovascular repair of blunt thoracic aortic injury (BTAI) has dramatically reduced the morbidity and mortality of intervention. Injuries requiring zone 2 coverage of the aorta traditionally require left subclavian artery (LSA) sacrifice or open revascularization. Furthermore, these injuries are associated with an increased risk of in-hospital mortality and long-term morbidity. Here we report 1-year outcomes of total endovascular repair of BTAI with the GORE® TAG® Thoracic Branch Endoprosthesis for LSA preservation. METHODS: Across 34 investigative sites, 9 patients with BTAI requiring LSA coverage were enrolled in a nonrandomized, prospective study of a single-branched aortic endograft. The thoracic branch endoprosthesis device allows for graft placement proximal to the LSA and incorporates a single side branch for LSA perfusion. RESULTS: This initial cohort included 8 male and 1 female patient with a median age of 43 (22, 76) and 12 months of follow-up. Five total years of follow-up are planned. All participants had grade 3 BTAI. All procedures took place between 2018 and 2019. The median injury severity score was 2 (0, 66). The median procedure time was 109 min (78, 162). All aortic injuries were repaired under general anesthesia and with heparinization. A spinal drain was used in one patient. Post-deployment balloon angioplasty was conducted in one case at the distal landing zone. There was one asymptomatic LSA branch occlusion 6 months after repair. It was attributed to the purposeful proximal deployment of the branch stent to accommodate an early vertebral takeoff. The occlusion did not require revascularization. There were no strokes, mortalities, or aortic adverse events (migration, endoleak, native aortic expansion, dissection, or thrombosis) through 12 months of follow-up. CONCLUSIONS: Initial cohort outcomes suggest that endovascular repair of zone 2 BTAI is feasible and has favorable outcomes using the thoracic branch device with LSA preservation. Additional cases and longer-term follow-up are required for a definitive assessment of the device's safety and durability in traumatic aortic injuries.

Outcomes of Endovascular and Open Surgical Therapy for Popliteal Artery Injury.

BACKGROUND: Popliteal arterial injury carries an appreciable risk of limb loss and, despite advances in stent and stent-graft technology, endovascular therapy for popliteal arterial trauma is infrequently used when compared with traditional open repair. Thus, this study aims to assess outcomes of endovascular management (EM) with open surgery (OS) as a historical reference. METHODS: An electronic search was performed (from January 2010 until June 2023) using multiple databases. Initial records were screened against eligibility criteria. Next, the full-text manuscript of articles that passed the title and abstract assessment was reviewed for relevancy of data points. Data from articles passing the inclusion criteria were extracted and tabulated. Comparative analysis was completed by performing chi-square tests and 2-sampled t-tests (Welch's). RESULTS: The 24 selected studies described 864 patients (96 EM; 768 OS). In the endovascular group, patients underwent procedures primarily for blunt trauma using covered, self-expanding stents, resulting in universal technical success and patency. Patients had an average length of stay of 7.99 ± 7.5 days and follow-up time of 33.0 ± 7.0 months, with 21% undergoing fasciotomies, 6% undergoing amputation, and 4% having pseudoaneurysms. Patients in the OS group were evenly divided between blunt and penetrating trauma, chiefly undergoing vein graft interposition and exhibiting fasciotomy and amputation rates of 66% and 24%, respectively. Patients had an average length of stay of 5.66 ± 4.6 days and a 96% survival rate at discharge. CONCLUSIONS: The current evidence sheds light on the nature of treatment offered by EM and OS treatment and suggests EM is associated with several important positive outcomes. Although it is difficult to directly compare endovascular and open surgical techniques, the data with respect to open surgical management of popliteal artery trauma can still provide a powerful frame of reference for the outcomes of EM to date. However, this claim is weak due to the little published data for EM of popliteal trauma, publication bias accompanying the published studies, and general, selection bias. Additional prospective data are necessary to define patients who specifically benefit from endovascular repair.

Risk Factors for Venous Thromboembolism and Eventual Amputation in Traumatic Femoral and Iliac Vein Injuries: A Trauma Quality Improvement Program Analysis.

BACKGROUND: Iliac and femoral venous injuries represent a challenging dilemma in trauma surgery with mixed results. Venous restoration of outflow (via repair or bypass) has been previously identified as having higher rates of VTE (venous thromboembolism) compared to ligation. We hypothesized that rates of VTE and eventual amputation were similar whether restoration of venous outflow vs ligation was performed at initial operation. METHODS: Patients in the 2019-2021 National Trauma Data Bank with iliac and femoral vein injuries were abstracted and analyzed. The primary outcomes of interest were in-hospital lower extremity amputation and VTE. RESULTS: A total of 2642 patients with operatively managed iliac and femoral vein injuries were identified VTE was found in 10.8% of patients. Multivariable logistic regression was performed and identified bowel injury, higher ISS, older age, open repair, and longer time to VTE prophylaxis initiation as independent predictors of VTE. Amputation was required in 4.2% of patients. Multivariable logistic regression identified arterial or nerve injury, femur or tibia fracture, venous ligation, percutaneous intervention, fasciotomy, bowel injury, and higher ISS as independent factors of amputation. CONCLUSION: Venous restoration was not an independent predictor of VTE. Venous ligation on index operation was the only modifiable independent predictor of amputation identified on regression analysis.

Pediatric Peripheral Vascular Trauma: Incidence and Outcomes.

Peripheral vascular trauma (PVT) is rare in children, with an incidence estimated below 1%. We studied pediatric PVT and risk factors for major amputation by accessing the 2019 National Trauma Data Bank (NTDB). Demographics, injury type and location, trauma center capability, injury severity score (ISS), length of stay (LOS), and major amputation rates were evaluated. Statistical analysis included chi-square testing for categorical variables and t-tests for continuous variables. Of 130,554 pediatric trauma patients, 1196 (.9%) had 1460 upper extremity (UE) and lower extremity (LE) PVT. Patients were predominantly male (n = 933, 78%) with a mean age of 14 years. Most patients suffered penetrating injury (n = 744, 62.2%). The most common vessels injuries were radial (n = 198, 13.6%) and femoral (n = 196, 13.4%). Major amputation occurred in 2.6% of patients (n = 31). Patients who suffered blunt injury (OR, 3.3; 95% CI, 1.5-7.5; P = .004) and lower limb PVT (OR, 11.1; 95% CI, 3.3-37.9, P = .0001) had higher odds of amputation.

Open versus endovascular repair of penetrating non-aortic arterial injuries: A systematic review and meta analysis.

BACKGROUND: Non-aortic arterial injuries are common and are associated with high morbidity and mortality. Historically, open surgical repair (OSR) was the conventional method of repair. With recent advancements in minimally invasive techniques, endovascular repair (ER) has gained popularity. We sought to compare outcomes in patients undergoing endovascular and open repairs of traumatic non-aortic penetrating arterial injuries. METHODS: A systematic review and meta-analysis was conducted using MEDLINE (OVID), Web of Science, Cochrane Library, and Scopus Database from January 1st, 1990, to March 20th, 2023. Titles and abstracts were screened, followed by full text review. Articles assessing clinically important outcomes between OSR and ER in penetrating arterial injuries were included. Exclusion criteria included blunt injuries, aortic injuries, pediatric populations, review articles, and non-English articles. Odds ratios (OR) and Cohen's d ratios were used to quantify differences in morbidity and mortality. RESULTS: A total of 3770 articles were identified, of which 8 met inclusion criteria and were included in the review. The articles comprised a total of 8369 patients of whom 90 % were male with a median age of 28 years. 85 % of patients were treated with OSR while 15 % underwent ER. With regards to injury characteristics, those who underwent ER were less likely to present with concurrent venous injuries (OR: 0.41; 95 %CI: 0.18, 0.94; p = 0.03). Regarding hospital outcomes, patients who underwent ER had a lower likelihood of in-hospital or 30-day mortality (OR: 0.72; 95 %CI: 0.55, 0.95; p = 0.02) and compartment syndrome (OR: 0.29, 95 %CI: 0.12, 0.71; p = 0.007). The overall risk of bias was moderate. CONCLUSION: Endovascular repair of non-aortic penetrating arterial injuries is increasingly common, however open repair remains the most common approach. Compared to ER, OSR was associated with higher odds of compartment syndrome and mortality. Further prospective research is warranted to determine the patient populations and injury patterns that most significantly benefit from an endovascular approach. LEVEL OF EVIDENCE: Level III, Systematic Reviews & Meta-Analyses.

Predictive Factors of Intestinal Ischaemia in Adhesive Small Bowel Obstruction.

OBJECTIVE: To identify the predictive factors of intestinal ischaemia in adhesive small bowel obstruction (ASBO) and develop an intestinal ischaemia risk score. STUDY DESIGN: Observational study. Place and Duration of the Study: Department of General Surgery, Shandong Provincial Qianfoshan Hospital, Jinan, Shandong, China, from January 2017 to February 2022. METHODOLOGY: ASBO was determined by findings at laparotomy. The assessment of small bowel's viability was conducted through surgical inspection and subsequent histological examination of the surgical specimen. Univariate and multivariate analyses were conducted to ascertain the risk factors associated with intestinal ischaemia. RESULTS: In total, 79 patients were included. Factors entered into multivariate analysis associated with intestinal ischaemia were; rebound tenderness (odds ratio (OR): 7.8, 95% confidence interval (CI):1.7-35.3; p=0.008), procalcitonin (PCT) >0.5 ng/mL (OR: 11.7, 95% CI: 2.3-58.1; p=0.003), and reduced bowel wall enhancement on computerised tomography (CT) scan (OR: 12.2, 95% CI:2.4-61.5; p=0.003). Among patients with 0, 1, 2, and 3 factors, the rate of intestinal ischaemia increased from 0% to 49%, 72%, and 100%, respectively. According to the number of risk factors, the area under the receiver operating characteristic curve for the determination of intestinal ischaemia was 0.848 (95% CI: 0.764-0.932). CONCLUSION: Rebound tenderness, PCT levels >0.5 ng/mL, and reduced bowel wall enhancement are risk factors of intestinal ischemic injury that require surgery within the context of ASBO. These factors need to be closely monitored that could assist clinicians in avoiding unnecessary laparotomies and selecting patients eligible for surgery. KEY WORDS: Intestinal obstruction, Ischaemia, Adhesions.

Management of vascular injuries on ICU patients: KZN experience.

BACKGROUND: Vascular injury management remains an extremely challenging task. The fundamental principles of management are bleeding arrest and flow restoration, to avoid death and amputation. With advances in medicine, there has been a shift from ligation to primary repair which has resulted in a fall in amputation rate from 50 % in World War II to less than 2 % in civilian injuries. METHOD: A retrospective cross-sectional study was conducted on ICU requiring polytrauma patients with vascular trauma admitted between January 2013 and December 2021. Additional data were collected prospectively from January 2022 to December 2022. All data was from an ethics approved Trauma Registry. The injury was either confirmed by imaging or via exploration. The pre-designed data proforma acquired the following variables: age, mechanism of injury, injured vessel, associated injury, management of the vessel, and management of the associated injury. The data were analysed using Stata version 17 (StataCorp, College Station TX). Frequencies and percentages were calculated to summarise numerical data An ethical clearance was granted by the University of KwaZulu-Natal BREC (BREC 0004353/2022) and the KZN Department of Health. All data were de-identified in the data collection sheet. RESULTS: There were 154 arterial injuries and 39 venous injuries. The majority, 77 (50 %) of arterial injuries were managed via open strategies, and 36 (23 %) were managed via endovascular intervention. The majority, 20 (51 %) of venous injuries underwent open ligation, and 12 (31 %) were managed non-surgically. The highest number of endovascular interventions was observed in aortic injuries. For a total of 25 aortic injuries, 22 (83 %) were managed endovascular (TEVAR) and 2 (8 %) were managed non-operatively. CONCLUSION: The choice between the endovascular and open approach depends on the injured blood vessel. The majority of venous injuries were treated with open ligation in this cohort.