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1.
J Surg Res ; 257: 363-369, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32892132

RESUMO

BACKGROUND: Popliteal artery injuries are the second most common arterial injuries below the inguinal ligament. We aimed to compare outcomes in patients with popliteal injuries by hospital teaching status utilizing the National Trauma Data Bank Research Data Set (NTDB-RDS) 2013-2016. METHODS: Four-year retrospective study using the NTDB-RDS, evaluating popliteal vascular injuries. Patients were divided by popliteal injury type and teaching status into; nonteaching hospital (NTH), community teaching (CTH), or University teaching (UTH). Demographics and outcome measures were compared between groups. Risk-adjusted mortality odds ratios (ORs) were calculated. Significance was defined as P < 0.05. RESULTS: 3,577,168 patients were in the NTDB-RDS, with 1120 having a popliteal injury, (incidence = 0.03%). There was no significant difference in the amputation rate between patients treated in NTHs, CTHs, or UTHs (P > 0.05). There was no significant difference in the raw mortality rate between patients treated in NTHs, CTHs, or UTHs. After adjusting for confounders; compared to NTH, the odds ratio for mortality for popliteal artery injuries in the CTH group was significantly higher (OR: 15.95, 95% CI: 1.19-213.84), and for the UTH group the mortality was also significantly higher (OR: 5.74, 95% CI: 0.45-72.95). CONCLUSIONS: The incidence of popliteal vascular injuries was 0.03% for 2013-2016. Patients with popliteal artery injuries treated at community teaching hospitals have a 16 times higher risk of mortality and at university teaching hospitals have a 5.7 times higher risk of mortality than patients treated at nonteaching hospitals.


Assuntos
Hospitais Universitários/estatística & dados numéricos , Artéria Poplítea/lesões , Lesões do Sistema Vascular/mortalidade , Adolescente , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados Unidos/epidemiologia , Adulto Jovem
2.
Ann Vasc Surg ; 69: 141-145, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32505682

RESUMO

BACKGROUND: The aim of this study is to compare wound infection, graft infection, and secondary amputation rates in patients who had popliteal artery injury repair with interposition vein versus prosthetic grafts. METHODS: This retrospective comparative study included all adult patients (>18 years) who had interposition grafting for popliteal artery injuries between January 2008 and August 2018 at a university hospital. Patients were divided into 2 groups. Popliteal arteries were repaired with venous graft in Group "A" and with prosthetic graft in Group "B." The outcome measures were wound infection, graft infection, and secondary amputation rates. RESULTS: Forty patients fulfilled the inclusion criteria. Twenty-two patients had arterial repair with venous while 18 with polytetrafluoroethylene grafts. All were male with median age of 32 (interquartile range [IQR] 19.5) years. Both groups were comparable in terms of median age (32.5 [19] vs. 30.5 [23]), Mangled Extremity Severity Score (6 [5] vs. 7 [7]), median hospital stay (7 [5] vs. 7 [9] days), and perioperative complications (2/22 vs. 3/18). In Group "A," no patient had graft infection or secondary amputation while in Group "B," 1 patient had secondary amputation and another had graft infection (P > 0.99). CONCLUSIONS: There is no statistical difference in secondary amputation rate, wound infection, or graft infection in patients undergoing popliteal artery repair with interposition vein versus prosthetic grafts in trauma setting.


Assuntos
Implante de Prótese Vascular , Artéria Poplítea/cirurgia , Lesões do Sistema Vascular/cirurgia , Veias/transplante , Adolescente , Adulto , Amputação , Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Humanos , Salvamento de Membro , Masculino , Pessoa de Meia-Idade , Artéria Poplítea/diagnóstico por imagem , Artéria Poplítea/lesões , Infecções Relacionadas à Prótese/microbiologia , Infecções Relacionadas à Prótese/cirurgia , Estudos Retrospectivos , Fatores de Risco , Infecção da Ferida Cirúrgica/microbiologia , Infecção da Ferida Cirúrgica/cirurgia , Fatores de Tempo , Resultado do Tratamento , Lesões do Sistema Vascular/diagnóstico por imagem , Adulto Jovem
3.
J Endovasc Ther ; 27(4): 575-580, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32419593

RESUMO

PURPOSE: To investigate if imaging with intravascular ultrasound (IVUS) yields a more accurate estimate of vessel diameter and the presence of dissections than angiography after intervention in the infrapopliteal arteries. MATERIALS AND METHODS: A prospective, single-center study enrolled 20 consecutive patients (mean age 74.1±12.4 years; 12 women) with infrapopliteal disease who were treated with percutaneous transluminal angioplasty (PTA; n=10) or orbital atherectomy (OA) followed by PTA (n=10). The majority of patients were hypertensive and half were diabetic. The overall lesion length was 7.3±6.3 cm, and the diameter stenosis was 80.3%±22.1%. The baseline characteristics did not differ between the groups. Vessel diameters were measured using IVUS from the internal elastic lamina (IEL) to the IEL. IVUS was performed at baseline, post PTA or OA, and post OA+PTA. Quantitative vascular angiography (QVA) and IVUS were analyzed by a core laboratory. Dissections on cine images were categorized based on the National Heart Lung and Blood Institute (NHLBI) classification, while the arc and depth were used to characterize dissections on IVUS images. RESULTS: Mean vessel diameter by QVA was 2.9±0.6 vs 4.0±1.0 mm by IVUS according to the core laboratory (mean difference 1.1±0.9, p<0.001). On angiography, there were 7 dissections after PTA (6 C, 1 D), 1 dissection after OA (1 B), and 2 dissections after OA+PTA (1 A, 1 B; p=0.028 vs post PTA). IVUS uncovered 3.8 times more dissections than seen on angiography. There were 23 dissections after PTA (18 intima, 3 media, 2 adventitia), 12 dissections after OA (8 intima, 1 media, 3 adventitia), and 11 dissections following OA+PTA (7 intima, 1 media, 3 adventitia; p=0.425 vs PTA). Bailout stenting (all due to angiographic dissections ≥C) was necessary in 6 of the PTA cohort and none of the OA+PTA group. CONCLUSION: In addition to underestimating the infrapopliteal vessel diameter by ~25%, angiography underappreciated the presence and severity of post-intervention dissections vs IVUS, particularly in the OA+PTA group.


Assuntos
Angioplastia com Balão/efeitos adversos , Aterectomia/efeitos adversos , Isquemia/terapia , Perna (Membro)/irrigação sanguínea , Doença Arterial Periférica/terapia , Artéria Poplítea/diagnóstico por imagem , Radiografia Intervencionista , Ultrassonografia de Intervenção , Lesões do Sistema Vascular/diagnóstico por imagem , Idoso , Idoso de 80 Anos ou mais , Angioplastia com Balão/instrumentação , Aterectomia/instrumentação , Doença Crônica , Feminino , Humanos , Isquemia/diagnóstico por imagem , Isquemia/fisiopatologia , Salvamento de Membro , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/fisiopatologia , Artéria Poplítea/lesões , Artéria Poplítea/fisiopatologia , Valor Preditivo dos Testes , Estudos Prospectivos , Radiografia Intervencionista/efeitos adversos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia de Intervenção/efeitos adversos , Grau de Desobstrução Vascular , Lesões do Sistema Vascular/etiologia , Lesões do Sistema Vascular/fisiopatologia
4.
Ann Vasc Surg ; 68: 468-475, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32422286

RESUMO

BACKGROUND: The spiral saphenous vein graft is an excellent choice for venous reconstruction after periphery vein injury, but only few cases have been reported. We implanted a segment of a single saphenous vein into both the popliteal vein as a venous vein graft and into the popliteal artery as an arterial vein graft at the same time in a trauma patient; we then had an extraordinary opportunity to harvest and examine both patent venous and arterial vein grafts at 2 weeks after implantation. METHODS: A spiral saphenous vein graft was made as previously described and implanted into the popliteal vein and artery as interposition grafts; because of the patient's serious injuries, an amputation was performed at day 18 after vascular reconstruction. The grafts were harvested, fixed, and examined using histology and immunohistochemistry. RESULTS: Both grafts were patent, and there was a larger neointimal area in the venous graft compared to the arterial graft. There were CD31- and vWF-positive cells on both neointimal endothelia, with subendothelial deposition of α-actin-, CD3-, CD45-, and CD68-positive cells. There were fewer cells in the venous graft neointima compared to the arterial graft neointima; however, there were more inflammatory cells in the neointima of the venous graft. Some of the neointimal cells were PCNA-positive, whereas very few cells were cleaved caspase-3 positive. The venous graft neointimal endothelial cells were Eph-B4 and COUP-TFII positive, while the arterial graft neointimal endothelial cells were dll-4 and Ephrin-B2 positive. CONCLUSIONS: The spiral saphenous vein graft remains a reasonable choice for vessel reconstruction, especially in the presence of diameter mismatch. Both the venous and arterial grafts showed similar re-endothelialization and cellular deposition; the venous graft had more neointimal hyperplasia and inflammation. At an early time, endothelial cells showed venous identity in the venous graft, whereas endothelial cells showed arterial identity in the arterial graft. CLINICAL RELEVANCE: Veins can be used as venous or arterial vein grafts but venous grafts have more neointimal hyperplasia and inflammation; vein grafts acquire different vessel identity depending on the environment into which they are implanted.


Assuntos
Plasticidade Celular , Células Endoteliais/patologia , Traumatismos da Perna/cirurgia , Artéria Poplítea/cirurgia , Veia Poplítea/cirurgia , Veia Safena/transplante , Enxerto Vascular , Lesões do Sistema Vascular/cirurgia , Amputação , Biomarcadores/metabolismo , Microambiente Celular , Células Endoteliais/metabolismo , Humanos , Escala de Gravidade do Ferimento , Traumatismos da Perna/diagnóstico , Traumatismos da Perna/metabolismo , Masculino , Pessoa de Meia-Idade , Neointima , Artéria Poplítea/lesões , Artéria Poplítea/metabolismo , Artéria Poplítea/patologia , Veia Poplítea/lesões , Veia Poplítea/metabolismo , Veia Poplítea/patologia , Veia Safena/metabolismo , Veia Safena/patologia , Resultado do Tratamento , Grau de Desobstrução Vascular , Remodelação Vascular , Lesões do Sistema Vascular/diagnóstico , Lesões do Sistema Vascular/metabolismo
6.
J Vasc Surg ; 72(1): 189-197, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32247701

RESUMO

OBJECTIVE: Traumatic popliteal artery injury is associated with an increased propensity for limb loss, morbidity, and mortality above an already elevated baseline risk to life and limb. Previous studies of outcomes in this patient group have been limited by selection bias. This study analyzed outcomes after blunt popliteal artery injury using propensity matching to reduce confounding variables associated with multiple mechanisms of traumatic vascular injury and to identify factors associated with amputation. METHODS: A retrospective review was conducted of prospectively collected data from the National Trauma Data Bank. Patients were identified using International Classification of Diseases, Ninth Revision codes related to patterns of blunt injury associated with popliteal arterial injury or intervention. Using Trauma Quality Improvement Program variables as a reference, specific characteristics were collected. Variables found significant on univariate analysis were used to generate propensity-matched amputation and nonamputation cohorts. Multivariate logistic regression was used to assess for risk factors associated with amputation and inpatient mortality. RESULTS: In total, 3029 patients with blunt popliteal artery injury were identified; 628 (20.7%) underwent amputation. Patients who underwent amputation presented with more frequent hypotension (systolic blood pressure of 0-99 mm Hg, 22.7% vs 12.8%; P < .001) and tachycardia (heart rate >120 beats/min, 28.5% vs 14.5%; P < .001). Limb loss was also associated with concurrent popliteal vein injury (18.3% vs 8.7%; P < .001) and tibial nerve injury (5.3% vs 1.3%; P < .001) as well as with elevated Injury Severity Score (median, 13 vs 9; P < .001) and lower extremity Abbreviated Injury Scale score (3 vs 2; P < .001). Subsequently, 794 patients were divided into equal number propensity-matched amputation and nonamputation cohorts. Regression analysis revealed that patients with diabetes mellitus (odds ratio [OR], 1.763; P = .049), popliteal vein injury (OR, 1.657; P = .012), or tibial nerve injury (OR, 3.537; P = .007) were more likely to undergo amputation. Further regression analysis with patients matched for Injury Severity Score revealed that age ≥86 years (OR, 38.092; P = .009), patellar fracture (OR, 3.445; P = .036), and elevated Abbreviated Injury Scale score (OR, 1.101; P < .001) were associated with higher risk of inpatient death. CONCLUSIONS: Trauma patients who sustain blunt popliteal artery injury are at an increased risk of amputation. Propensity-matched analysis revealed that concurrent popliteal vein and tibial nerve injury but not severity of tissue injury predicted limb loss.


Assuntos
Amputação , Artéria Poplítea/cirurgia , Lesões do Sistema Vascular/cirurgia , Ferimentos não Penetrantes/cirurgia , Adulto , Amputação/efeitos adversos , Amputação/mortalidade , Bases de Dados Factuais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Artéria Poplítea/diagnóstico por imagem , Artéria Poplítea/lesões , Pontuação de Propensão , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Lesões do Sistema Vascular/diagnóstico por imagem , Lesões do Sistema Vascular/mortalidade , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos não Penetrantes/mortalidade , Adulto Jovem
8.
BMC Musculoskelet Disord ; 21(1): 59, 2020 Jan 30.
Artigo em Inglês | MEDLINE | ID: mdl-32000749

RESUMO

BACKGROUND: Poplital artery transection injury is potentially catastrophic, or even life-threatening. Severe traumas, including open fracture, gunshot, stabs, and knee dislocation and complex fracture of proximal tibia or distal femur, are the common causes of high rate of amputation due to popliteal artery trauma. No report mentions vascular injury associated with minimally displaced tibial plateau fracture in adult. CASE PRESENTATION: A 30-year-old male presented with popliteal artery transection injury associated with minimally displaced tibial plateau fracture. He presented to emergency department, 6 h after fall from ground into a 1-m height hole. Physical examination suggested acute ischemia, with signs of paleness, coldness, anesthesia, hemorrhagic bullae below the right knee level. There was severe swelling and ecchymosis in popliteal fossa and around the leg with significant calf tenderness and pedal edema. Tibialis posterior, dorsalis pedis, and popliteal arterial pulses were not palpable. Radiograph suggested minimally displaced tibial plateau fracture with no evidence of knee dislocation. The patient was taken up for emergency surgery after consultation with vascular surgeon. During the closed reduction external fixation and compartment decompression, popliteal artery trunk was found transected and end-to-end repair was performed. During the post-operational period, no complication was developed and the patient was followed-up for 1 year. At the one-year follow-up, he acquired good stability of his right knee with full range of motion. CONCLUSION: Significant swelling and ecchymosis should alert the surgeons to the possibility of vascular injury in knee joint injury, even if there is no fracture or dislocation, or fracture is minimally displaced.


Assuntos
Artéria Poplítea/lesões , Artéria Poplítea/cirurgia , Fraturas da Tíbia/complicações , Fraturas da Tíbia/cirurgia , Adulto , Descompressão Cirúrgica/métodos , Fixadores Externos , Humanos , Masculino , Artéria Poplítea/diagnóstico por imagem , Fraturas da Tíbia/diagnóstico por imagem
10.
Vasc Endovascular Surg ; 54(4): 367-374, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32079503

RESUMO

OBJECTIVES: Infrapopliteal arterial pseudoaneurysms (IAP) following blunt trauma with associated orthopedic injuries are uncommon, often present in a delayed fashion, and encompass a diagnostic and therapeutic dilemma. Herein, we present a series of IAPs that were diagnosed following blunt trauma and their management. METHODS: Case series consisting of 3 patients and a review of the international literature. RESULTS: Our case series included 3 patients presenting with IAPs following blunt trauma with associated orthopedic injuries. They were all identified in a delayed manner (>3 weeks) after the orthopedic injuries were treated. All patients presented with pain and a pulsatile mass while one concurrently had neurologic deficits. The pseudoaneurysms were diagnosed by duplex ultrasound and confirmed by angiography to be originating from the tibioperoneal trunk, anterior tibial, and posterior tibial arteries respectively. Two patients were treated with surgical excision. Of these, one required an arterial bypass procedure while the other underwent direct ligation only. The third patient was treated by endovascular coiling. A literature review from 1950 to the present found 51 reported cases of IAP resulting from blunt trauma. Ninety percent of trauma-related infrapopliteal injuries occurred in men with a mean delay in diagnosis of 5.6 months (median 1.8 months) after injury. Since 1950, management has shifted from primarily ligation to incorporating minimally invasive endovascular techniques when appropriate. CONCLUSIONS: Infrapopliteal artery pseudoaneurysms are rare following blunt skeletal trauma. A delay in diagnosis often occurs and can result in major morbidity and extensive surgical intervention. We recommend a high index of suspicion and a thorough vascular examination in patients with lower extremity skeletal trauma to help identify and treat these injuries early and effectively.


Assuntos
Falso Aneurisma/etiologia , Artéria Poplítea/lesões , Lesões do Sistema Vascular/etiologia , Ferimentos não Penetrantes/etiologia , Acidentes de Trânsito , Adulto , Falso Aneurisma/diagnóstico por imagem , Falso Aneurisma/terapia , Diagnóstico Tardio , Embolização Terapêutica , Humanos , Ligadura , Masculino , Pessoa de Meia-Idade , Artéria Poplítea/diagnóstico por imagem , Artéria Poplítea/cirurgia , Valor Preditivo dos Testes , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares , Lesões do Sistema Vascular/diagnóstico por imagem , Lesões do Sistema Vascular/terapia , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos não Penetrantes/cirurgia
11.
Ann Vasc Surg ; 66: 242-249, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31978483

RESUMO

BACKGROUND: Popliteal artery injury (PAI) is a rare occurrence in pediatric patients with significant consequences. Delays in diagnosis lead to severe complications such as lifelong disability and limb loss. We sought to identify outcomes and clinical predictors of PAI in the pediatric trauma population. METHODS: The Pediatric Trauma Quality Improvement Program (2014-2016) was queried for patients ≤17 years old with PAI. Patient demographics and outcomes were characterized. A comparison of patients sustaining blunt versus penetrating PAI was performed. A multivariable logistic regression analysis was used to identify predictors of PAI. RESULTS: From 119,132 patients, 58 (<0.1%) sustained a PAI with 74.1% from blunt trauma. Most of the patients were male (75.9%) with a median age of 15 and median Injury Severity Score of 9. A majority of the patients were treated with open repair (62.1%) in comparison to endovascular repair (10.3%) and nonoperative management (36.2%). The rates of open and endovascular repair and nonoperative management were similar between blunt and penetrating PAI patients (P = not significant). Concomitant injuries included popliteal vein injury (PVI) (12.1%), posterior tibial nerve injury (3.4%), peroneal nerve injury (3.4%), and closed fracture/dislocation of the femur (22.4%), patella (25.9%), and tibia/fibula (29.3%). Overall complications included compartment syndrome (8.6%), below-knee amputation (6.9%), and above-knee amputation (3.4%). The overall mortality was 3.4%. Patients with PAI secondary to penetrating trauma had a higher rate of concomitant PVI (26.7% vs. 7%, P = 0.04) and posterior tibial nerve injury (13.3% vs. 0%, P = 0.02) but a lower rate of closed fracture/dislocation of the patella (0% vs. 34.9%, P = 0.008) and tibia/fibula (0% vs. 39.5%, P = 0.004) compared to patients with PAI from blunt trauma. Predictors for PAI included PVI (odds ratio [OR] 296.57, confidence interval [CI] = 59.21-1,485.47, P < 0.001), closed patella fracture/dislocation (OR 50.0, CI = 24.22-103.23, P < 0.001), open femur fracture/dislocation (OR 9.05, CI = 3.56-22.99, P < 0.001), closed tibia/fibula fracture/dislocation (OR 7.44, CI = 3.81-14.55, P < 0.001), and open tibia/fibula fracture/dislocation (OR 4.57, CI = 1.80-11.59, P < 0.001). PVI had the highest association with PAI in penetrating trauma (OR 84.62, CI = 13.22-541.70, P < 0.001) while closed patella fracture/dislocation had the highest association in blunt trauma (OR 52.01, CI = 24.50-110.31, P < 0.001). CONCLUSIONS: A higher index of suspicion should be present for PAI in pediatric trauma patients presenting with a closed patella fracture/dislocation after blunt trauma. PVI is most strongly associated with PAI in penetrating trauma. Prompt recognition of PAI is crucial as there is a greater than 10% amputation rate in the pediatric population.


Assuntos
Procedimentos Endovasculares , Fratura-Luxação/terapia , Traumatismos da Perna/terapia , Artéria Poplítea/cirurgia , Veia Poplítea/cirurgia , Procedimentos Cirúrgicos Vasculares , Lesões do Sistema Vascular/terapia , Ferimentos não Penetrantes/terapia , Ferimentos Penetrantes/terapia , Adolescente , Fatores Etários , Amputação , Criança , Bases de Dados Factuais , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Fratura-Luxação/diagnóstico por imagem , Fratura-Luxação/mortalidade , Humanos , Traumatismos da Perna/diagnóstico por imagem , Traumatismos da Perna/mortalidade , Salvamento de Membro , Masculino , Artéria Poplítea/diagnóstico por imagem , Artéria Poplítea/lesões , Veia Poplítea/diagnóstico por imagem , Veia Poplítea/lesões , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/cirurgia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/mortalidade , Lesões do Sistema Vascular/diagnóstico por imagem , Lesões do Sistema Vascular/mortalidade , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos não Penetrantes/mortalidade , Ferimentos Penetrantes/diagnóstico por imagem , Ferimentos Penetrantes/mortalidade
12.
Arthroscopy ; 36(2): 492-498, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31901385

RESUMO

PURPOSE: We assessed the risk of injury to the popliteal neurovascular bundle (PNVB) while suturing the posterior horn of the lateral meniscus (PHLM). METHODS: We simulated all-inside suturing of the PHLM using magnetic resonance imaging of 60 knees. Lines were drawn from the medial and the lateral edges of the patellar tendon to the PHLM at increasing distances from the posterior cruciate ligament (PCL) to simulate suturing device trajectory. Distance from each line to the PNVB was measured (d). A similar analysis was performed using lines drawn from 1 cm medial and 1 cm lateral to the patellar tendon. We compared the average "d" at increasing distances from the PCL, between the different simulated portal entry points. We have also analyzed the association between different demographic characteristics and the shortest distance from the PVNB to the PHLM. RESULTS: Of 1200 measurements performed, the simulated suturing trajectory transected the PNVB 343 times (28.6%). At 0 mm from the PCL, the safest portal was the 1-cm lateral portal (P < .001), with an average "d" of 2.7 mm. At 3 mm, 6 mm, 9 mm, and 12 mm from the PCL, the safest portal was the 1-cm medial portal (P < .001), with average "d" of 3.8 mm, 6.9 mm, 10.1 mm, and 13.5 mm, respectively. Average distance between the PHLM and the PNVB was 7.8 mm. Shorter distance between the PHLM and the PNVB was associated with younger age and female sex (P = .014 and .001, respectively). CONCLUSIONS: All-inside suturing of the PHLM at 0 mm from the PCL is safer with a more lateral portal. Beyond 3 mm from the PCL, a more medial portal carries a lower risk to the PNVB. Young and female patients have a shorter distance between the PHLM and the PNVB, suggesting a greater risk for injury to the PNVB. Careful preoperative magnetic resonance imaging assessment may assist in safer portal selection when planning repair of the PHLM. CLINICAL RELEVANCE: This study describes a magnetic resonance imaging-based risk assessment for injury of the PVNB while suturing the PHLM. It allows the orthopaedic surgeon a better understanding of the anatomic relationship between the popliteal neurovascular bundle and the lateral meniscus and can assist in portal selection and safety.


Assuntos
Imagem por Ressonância Magnética/métodos , Meniscos Tibiais/cirurgia , Artéria Poplítea/lesões , Ligamento Cruzado Posterior/cirurgia , Técnicas de Sutura/instrumentação , Suturas , Lesões do Menisco Tibial/cirurgia , Lesões do Sistema Vascular/prevenção & controle , Adolescente , Adulto , Idoso , Feminino , Humanos , Masculino , Meniscos Tibiais/diagnóstico por imagem , Pessoa de Meia-Idade , Ligamento Patelar/cirurgia , Artéria Poplítea/diagnóstico por imagem , Lesões do Menisco Tibial/diagnóstico , Lesões do Sistema Vascular/diagnóstico , Adulto Jovem
13.
Knee Surg Sports Traumatol Arthrosc ; 28(5): 1425-1435, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-31119339

RESUMO

PURPOSE: (1) To analyse popliteal artery (PA) movement in a three-dimensional (3D) coordinate system in relation to knee flexion and high tibial osteotomy (HTO) techniques (lateral closed wedge HTO [LCHTO], uniplane medial open wedge HTO [UP-MOHTO], biplane medial open wedge HTO [BP-MOHTO]) and (2) to identify safe zones of the PA in each osteotomy plane. METHODS: Sixteen knees of patients who underwent magnetic resonance imaging with extension and 90° flexion were used to develop subject-specific 3D knee flexion models. Displacement of the PA during knee flexion was measured along the X- and Y-axis, as was the distance between the posterior tibial cortex and PA parallel to the Y-axis (d-PCA). Frontal plane safety index (FPSI) and maximal axial safe angles (MASA) of osteotomy, which represented safe zones for the osteotomy from the PA injury, were analysed. All measurements were performed along virtual osteotomy planes. Differences among the three osteotomy methods were analysed for each flexion angle using a linear mixed model. RESULTS: The average increments in d-PCA during knee flexion were 1.3 ± 2.3 mm in LCHTO (n.s.), 1.4 ± 1.2 mm in UP-MOHTO (P < 0.0001), and 1.7 ± 2.0 mm in BP-MOHTO (P = 0.015). The mean FPSIs in knee extension were 37.6 ± 5.9%, 46.4 ± 5.8%, and 45.1 ± 8.1% for LCHTO, UP-MOHTO, and BP-MOHTO, respectively. The mean MASA values in knee extension were 45.8° ± 4.4°, 37.3° ± 6.1°, and 38.9° ± 6.5° for LCHTO, UP-MOHTO, and BP-MOHTO, respectively. CONCLUSION: Although the PA moved posteriorly during knee flexion, the small (1.7 mm) increment thereof and inconsistent movements in subjects would not be of clinical relevance to PA safety during HTO. LEVEL OF EVIDENCE: Diagnostic study, Level II.


Assuntos
Osteoartrite do Joelho/cirurgia , Osteotomia/efeitos adversos , Osteotomia/métodos , Artéria Poplítea/lesões , Lesões do Sistema Vascular/prevenção & controle , Adulto , Simulação por Computador , Feminino , Humanos , Imageamento Tridimensional , Joelho/diagnóstico por imagem , Articulação do Joelho/diagnóstico por imagem , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Osteoartrite do Joelho/diagnóstico por imagem , Amplitude de Movimento Articular , Lesões do Sistema Vascular/etiologia , Adulto Jovem
14.
Ann Vasc Surg ; 62: 119-127, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31476424

RESUMO

BACKGROUND: By necessity, wartime arterial injuries undergo staged management. Initial procedures may occur at a forward surgical team (role 2), where temporary shunts can be placed before transfer to a larger field hospital (role 3) for definitive reconstruction. Our objective was to evaluate the impact of staging femoropopliteal injury care on limb outcomes. METHODS: A military vascular injury database was queried for Iraq/Afghanistan casualties with femoropopliteal arterial injuries undergoing attempted reconstruction (2004-2012). Cases were grouped by initial arterial management: shunt placed at role 2 (R2SHUNT), reconstruction at role 2 (R2RECON), and initial management at role 3 (R3MGT). The primary outcome was limb salvage; secondary outcomes were limb-specific complications. Descriptive and intergroup comparative statistics were performed with significance defined at P ≤ 0.05. RESULTS: Of 257 cases, all but 4 had definitive reconstruction before evacuation to Germany (median, 2 days): 46 R2SHUNT, 84 R2RECON, and 127 R3MGT; median Mangled Extremity Severity Score was 6 for all groups. R2SHUNT had median extremity Abbreviated Injury Scale--vascular of 4 (other groups, 3; P < 0.05) and was more likely to have concomitant venous injury and to undergo fasciotomy. Shunts were used for 5 ± 3 hr. About 24% of R2RECON repairs were revised at role 3. Limb salvage rate of 80% was similar between groups, and 62% of amputations performed within 48 hr of injury. Rates of limb and composite graft complications were similar between groups. Thrombosis was more common in R2SHUNT (22%) than R2RECONST (6%) or R3MGT (12%) (P = 0.03). Late (>48 hr) thrombosis rates were similar, whereas 60% of R2SHUNT thromboses occurred on day of injury (P = 0.003 vs. 25% and 0%). CONCLUSIONS: Staged femoropopliteal injury care is associated with similar limb salvage to initial role 3 management. Early thrombosis is likely because of shunt failure but does not lead to limb loss. Current military practice guidelines are appropriate and may inform civilian vascular injury management protocols.


Assuntos
Artéria Femoral/cirurgia , Artéria Poplítea/cirurgia , Procedimentos Cirúrgicos Vasculares , Lesões do Sistema Vascular/cirurgia , Campanha Afegã de 2001- , Amputação , Bases de Dados Factuais , Artéria Femoral/lesões , Humanos , Iraque , Salvamento de Membro , Medicina Militar , Militares , Artéria Poplítea/lesões , Complicações Pós-Operatórias/cirurgia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Transporte de Pacientes , Resultado do Tratamento , Estados Unidos , Procedimentos Cirúrgicos Vasculares/efeitos adversos
15.
Cardiovasc Revasc Med ; 21(1): 34-45, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31054801

RESUMO

BACKGROUND: Subintimal angioplasty (SIA) is often utilized to cross femoropopliteal (FP) artery chronic total occlusions (CTOs). Re-entry devices (RED) can further assist with true lumen re-entry. OBJECTIVE: To systematically review the literature for studies reporting on the use of SIA, with or without RED. METHODS: A systematic review according to the PRISMA guidelines was performed. Quantitative synthesis was applied when possible. RESULTS: 87 studies and 4665 patients (5161 lesions) were included (63.9% male). 46.7% of patients had critical limb ischemia at the time of the intervention. Two RED types were used (Pioneer and Outback). Sixty-eight studies included lesions treated with SIA without RED, 17 studies included lesions treated with RED only, and two studies included a comparison between the two treatment methods. In total, 3898 (83.6%) patients were treated with SIA without RED and 754 (12.2%) with RED. Procedural success rate ranged from 64.5%-100% (92.5% for SIA without RED, 88.3% for RED cases). The complication rate ranged from 1.6% - 28% among different studies (cumulative rates: SIA: 9.1%, RED 9.3%). Perforations occurred in 1.6% of the total population (n = 46). Primary patency at one year ranged from 22% to 94.1%. Newer studies had a higher patency rate, ranging from 70% to 94.1%. CONCLUSION: SIA with or without RED is a valuable alternative to intraluminal crossing for endovascular treatment of FP CTOs. Procedural success was excellent for both techniques, while the cumulative complication rate was numerically lower in the RED group. Short- and long-term outcomes were acceptable for both techniques.


Assuntos
Angioplastia/instrumentação , Artéria Femoral , Doença Arterial Periférica/terapia , Artéria Poplítea , Dispositivos de Acesso Vascular , Idoso , Idoso de 80 Anos ou mais , Angioplastia/efeitos adversos , Doença Crônica , Constrição Patológica , Desenho de Equipamento , Feminino , Artéria Femoral/diagnóstico por imagem , Artéria Femoral/lesões , Artéria Femoral/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/fisiopatologia , Artéria Poplítea/diagnóstico por imagem , Artéria Poplítea/lesões , Artéria Poplítea/fisiopatologia , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução Vascular , Lesões do Sistema Vascular/etiologia
16.
Ann Vasc Surg ; 62: 51-56, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31201972

RESUMO

BACKGROUND: Despite aggressive limb salvage attempts, military popliteal artery injuries are associated with high amputation rates. Combined arterial and venous injuries present a management dilemma for military surgeons in austere settings, and the impact of vein injury management strategy on limb outcomes is not clear. METHODS: Military casualties sustaining combined ipsilateral popliteal artery and vein injuries from 2003 to 2016 were identified from a military vascular injury database. Limbs were grouped based on whether venous ligation or repair was initially performed. The primary outcome was secondary amputation; the secondary outcomes included limb and vascular/graft complications. RESULTS: Fifty-six limbs were included; of which, 27 (48%) were managed with vein ligation and 29 (52%) with repair. Veins were repaired primarily in 13 (45%) cases with the remainder being treated with interposition grafts. Median injury severity score was higher in the ligation group (19 vs 15, P = 0.09), but vascular and concomitant limb injury characteristics were similar. Amputation rates did not differ by vein treatment (45% repair vs. 41% ligation, P = 0.76), and this held with injuries above and below the knee considered independently. Most (71%) amputations were performed <30 days from injury. Amputation was indicated more frequently for vascular repair failure in the ligated group (55% vs 15%, P = 0.04). Four graft infections were all in the repair group (P = 0.07 vs ligation). Arterial graft complications were more frequent with vein repair (45%) than ligation (30%), but this did not reach significance (P = 0.24). Only one deep vein thrombosis was diagnosed in each group (P = 0.96). CONCLUSIONS: Type of management of concomitant popliteal vein injury was not associated with early or late amputation in this series of military popliteal artery injuries. Vein injury management may have had implications for the development of arterial graft and limb complications, however. Surgical decision-making regarding popliteal vein treatment should balance short-term contingencies with long-term limb salvage issues.


Assuntos
Implante de Prótese Vascular , Militares , Artéria Poplítea/cirurgia , Veia Poplítea/cirurgia , Procedimentos Cirúrgicos Reconstrutivos , Lesões do Sistema Vascular/cirurgia , Adulto , Amputação , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Humanos , Ligadura , Salvamento de Membro , Medicina Militar , Artéria Poplítea/lesões , Veia Poplítea/lesões , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Procedimentos Cirúrgicos Reconstrutivos/efeitos adversos , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
17.
Knee Surg Sports Traumatol Arthrosc ; 28(5): 1365-1371, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-30809721

RESUMO

PURPOSE: Popliteal artery injury is a rare but devastating complication of open-wedge high tibial osteotomy (OWHTO). The objectives of this study were: to document the location of the artery in the virtual osteotomy plane (VOP), to measure the minimal distance between the popliteal artery and three virtual saw-progression lines (VSLs), and to present a safe sawing technique for OWHTO. METHOD: In total, 45 computed tomography angiographies were reconstructed and virtual osteotomy was simulated using 3D image-processing software. The VOP was defined as an inclined plane commencing 3.5 cm below the articular plane towards the fibular head. VSLs were defined as saw-progression guidelines that lie on the VOP: "VSL-mid" runs from the midpoint of the tibial medial cortex towards the fibular head; "VSL-ant" starts from the same point as VSL-mid, but runs 10° anterior to the fibular head; and "VSL-post" runs 10° posterior to the fibular head. The distances between the popliteal artery and the three VSLs were measured, and the risk of injury was assessed. RESULTS: The popliteal artery was located 20.7° posterior to VSL-mid and 51 mm from the starting point. The minimum distance between the popliteal artery and VSL-mid was 18 mm (99% confidence interval 9-27 mm). When the saw was moved along VSL-mid, 42% of the arteries were susceptible to injury. However, when it followed VSL-ant, there was no risk of injury. CONCLUSIONS: Sawing toward the fibular head carries a risk of popliteal artery injury and should not be performed. When sawing in OWHTO, the recommended target should be 10° anterior to the fibular head. This technique eliminates the risk of popliteal artery injury.


Assuntos
Osteotomia/efeitos adversos , Osteotomia/métodos , Artéria Poplítea/lesões , Tíbia/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Angiografia por Tomografia Computadorizada , Feminino , Fíbula , Humanos , Imageamento Tridimensional , Masculino , Pessoa de Meia-Idade , Osteoartrite do Joelho/cirurgia , Artéria Poplítea/anatomia & histologia , Artéria Poplítea/diagnóstico por imagem , Complicações Pós-Operatórias , Fatores de Risco , Tíbia/diagnóstico por imagem
18.
J Endovasc Ther ; 27(1): 102-108, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31724469

RESUMO

Purpose: To evaluate a new scoring balloon, the non-slip element (NSE) percutaneous transluminal angioplasty (PTA) balloon, in the treatment of femoropopliteal lesions by comparing angiographic dissection patterns to those of a conventional balloon. Methods: This retrospective, single-center study included 71 symptomatic patients (mean age 77.4±8.8 years; 33 men) with de novo femoropopliteal lesions <20 cm long treated with balloon angioplasty between January 2017 and May 2018. Thirty-four patients were treated with 3 inflations of an NSE balloon and 37 patients were treated with a conventional balloon. Results: Severe dissections were fewer (8.8% vs 29.7%, p=0.027) and the total dissection length was shorter (11.5±12.8 vs 35.7±24.1 mm, p=0.027) in the NSE group. The bailout stenting rate was also lower in the NSE group (17.6% vs 40.5%, p=0.035). There were no significant differences between the groups regarding lesion length (70.3±50.4 vs 77.8±56.6 mm, p=0.28), inflation time (294±162 vs 353±179 seconds, p=0.08), or inflation pressure (10.6±5.0 vs 11.3±5.3 atm, p=0.31). Conclusion: Three NSE balloon inflations may reduce severe dissections induced by balloon angioplasty in femoropopliteal lesions.


Assuntos
Angioplastia com Balão/instrumentação , Artéria Femoral/lesões , Doença Arterial Periférica/terapia , Artéria Poplítea/lesões , Dispositivos de Acesso Vascular , Lesões do Sistema Vascular/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Angioplastia com Balão/efeitos adversos , Desenho de Equipamento , Feminino , Artéria Femoral/diagnóstico por imagem , Artéria Femoral/fisiopatologia , Humanos , Japão , Masculino , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/fisiopatologia , Artéria Poplítea/diagnóstico por imagem , Artéria Poplítea/fisiopatologia , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Stents , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução Vascular , Lesões do Sistema Vascular/diagnóstico por imagem , Lesões do Sistema Vascular/etiologia , Lesões do Sistema Vascular/fisiopatologia
19.
J Pediatr Surg ; 55(2): 319-323, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31761459

RESUMO

BACKGROUND: The purpose of this study was to evaluate the epidemiology and management of pediatric vascular extremity trauma to assess injury patterns and other factors that may contribute to poor outcomes. METHODS: Using the California Office of Statewide Health Planning and Development discharge database, we identified pediatric patients with extremity arterial trauma admitted to acute-care hospitals from 2007 to 2014. Demographics, management patterns, and outcomes were collected and analyzed. RESULTS: A total of 775 patients were treated for an extremity arterial injury. Overall, 40% were admitted to pediatric trauma centers and 39% to adult trauma centers. Management was predominantly by open surgical repair. Injury to the common femoral artery was associated with mortality (Hazard Ratio 3.9; 95% CI 1.1-14.5; p < 0.05). Popliteal artery injuries (Odds Ratio [OR] 4.8; 95% CI 1.2-19.9; p < 0.05) and anterior tibial artery injuries (OR 7.1; 95% CI 1.4-37.3; p < 0.05) had an increased risk of amputation. There was no difference in amputation or mortality rates by hospital category. CONCLUSIONS: Pediatric extremity arterial injuries are rare. In California, outcomes are similar by hospital type. Common femoral artery injuries are associated with an increased risk of mortality, while popliteal and anterior tibial artery injuries are associated with an increased risk of amputation. TYPE OF STUDY: Prognosis Study. LEVEL OF EVIDENCE: Level III.


Assuntos
Procedimentos Cirúrgicos Vasculares , Lesões do Sistema Vascular/cirurgia , Amputação , Criança , Humanos , Extremidade Inferior/irrigação sanguínea , Extremidade Inferior/cirurgia , Artéria Poplítea/lesões , Artéria Poplítea/cirurgia , Resultado do Tratamento
20.
J Trauma Acute Care Surg ; 88(2): 197-206, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31804418

RESUMO

BACKGROUND: Traumatic popliteal arterial injury (TPAI) is associated with a risk of both limb loss and long-term morbidity due to prolonged ischemia and the often-associated musculoskeletal injuries. Long-term functional outcome following this injury has not been adequately studied. We evaluated patients with TPAI to determine if there was an improvement in functional outcome over time. We hypothesized that both the initial severity of ischemia and the associated injuries limited the ability of patients to improve functional outcome. METHODS: Patients with TPAI for 20 years were identified. All patients had at least a 2-year follow-up. Functional outcomes were measured using the Boston University Activity Measure for Post-Acute Care to assess basic mobility (BM) and daily activity (DA). Multiple linear regression, adjusted for age, severity of injury and shock, operative complexity, associated injuries, ischemic time, and length of follow-up were used to identify predictors of functional outcome after TPAI. RESULTS: A total of 214 patients were identified: 123 penetrating (57%) and 91 blunt (43%). Overall mortality was 1.9% (all in-hospital), and amputation occurred in 10%. Of the 210 survivors, follow-up was obtained in 145 patients (69%). Median follow-up was 9.2 years (interquartile range, 5.7-15.7 years). Mean Activity Measure for Post-Acute Care scores for BM and DA were 78 and 75, respectively, both signifying mild impairment (normal, >84). Multiple linear regression failed to identify increasing length of follow-up as a predictor of improved functional outcomes. Only age, lower extremity fracture, and ischemic time were identified as predictors of decreased BM and DA. CONCLUSION: Increasing age, lower extremity fracture, and prolonged ischemic time worsened long-term functional outcomes. Functional outcome did not improve over time, suggesting that maximal recovery may be achieved within the first 2 years postinjury. Thus, early and effective revascularization remains the only potentially modifiable risk factor for improving functional outcomes following TPAI. LEVEL OF EVIDENCE: Prognostic, level III.


Assuntos
Amputação/estatística & dados numéricos , Procedimentos Endovasculares , Isquemia/cirurgia , Traumatismos da Perna/cirurgia , Extremidade Inferior/irrigação sanguínea , Atividades Cotidianas , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Mortalidade Hospitalar , Humanos , Isquemia/etiologia , Isquemia/mortalidade , Traumatismos da Perna/complicações , Traumatismos da Perna/mortalidade , Masculino , Pessoa de Meia-Idade , Artéria Poplítea/lesões , Artéria Poplítea/cirurgia , Prognóstico , Sobreviventes/estatística & dados numéricos , Resultado do Tratamento , Adulto Jovem
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