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1.
Vasc Endovascular Surg ; 54(1): 36-41, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31570064

RESUMO

OBJECTIVES: Although traumatic injuries to the superior mesenteric vein (SMV), portal vein (PV), and hepatic vein (HV) are rare, their impact is significant. Small single center reports estimate mortality rates ranging from 29% to 100%. Our aim is to elucidate the incidence and outcomes associated with each injury due to unique anatomic positioning and varied tolerance of ligation. We hypothesize that SMV injury is associated with a lower risk of mortality compared to HV and PV injury in adult trauma patients. METHODS: The Trauma Quality Improvement Program database (2010-2016) was queried for patients with injury to either the SMV, PV, or HV. A multivariable logistic regression model was used for analysis. RESULTS: From 1,403,466 patients, 966 (0.07%) had a single major hepatoportal venous injury with 460 (47.6%) involving the SMV, 281 (29.1%) involving the PV, and 225 (23.3%) involving the HV. There was no difference in the percentage of patients undergoing repair or ligation between SMV, PV, and HV injuries (P > .05). Compared to those with PV and HV injuries, patients with SMV injury had a higher rate of concurrent bowel resection (38.5% vs 12.1% vs 7.6%, P < .001) and lower mortality (33.3% vs 45.9% vs 49.3%, P < .01). After controlling for covariates, traumatic SMV injury increased the risk of mortality (odds ratio [OR] 1.59, confidence interval [CI] = 1.00-2.54, P = .05) in adult trauma patients; however, this was less than PV injury (OR = 2.77, CI = 1.56-4.93, P = .001) and HV injury (OR = 2.70, CI = 1.46-4.99, P = .002). CONCLUSION: Traumatic SMV injury had a lower rate of mortality compared to injuries of the HV and PV. SMV injury increased the risk of mortality by 60% in adult trauma patients, whereas PV and HV injuries nearly tripled the risk of mortality.


Assuntos
Veias Hepáticas/lesões , Veia Porta/lesões , Lesões do Sistema Vascular/epidemiologia , Adolescente , Adulto , Criança , Bases de Dados Factuais , Feminino , Veias Hepáticas/diagnóstico por imagem , Veias Hepáticas/cirurgia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Veia Porta/diagnóstico por imagem , Veia Porta/cirurgia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Lesões do Sistema Vascular/diagnóstico por imagem , Lesões do Sistema Vascular/mortalidade , Lesões do Sistema Vascular/cirurgia , Adulto Jovem
2.
J Surg Res ; 245: 179-182, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31421360

RESUMO

BACKGROUND: Blunt thoracic aortic injuries (BTAIs) carry a substantial mortality rate. Our study aimed to compare the outcomes of thoracic endovascular aortic repair (TEVAR) with open repair from trauma centers across the United States using the National Trauma Data Bank-Research Data Set (RDS). MATERIALS AND METHODS: The National Trauma Data Bank-RDS was reviewed for thoracic aortic injures and repair methods. Patients were divided into two groups: TEVAR versus open repair. Demographics and outcomes were compared between groups. Mortality rate was adjusted using the observed/expected mortality (O/E), with TRISS methodology by using the Revised Trauma Score with the Injury Severity Score. Chi-square test and t-test were used with significance defined as P < 0.05. RESULTS: Within the 2016 RDS, there were 275 cases that underwent operative repair for BTAI. Of the 275 operative cases, 62.5% (172/275) had TEVAR and 37.5% (103/275) underwent open repair. Mean age in TEVAR group was 41 and open repair group was 36 (P > 0.05). Mean Injury Severity Score for TEVAR was 36 versus 35 for open repair (P > 0.05). Mean Revised Trauma Score was 6.7 in TEVAR versus 5.5 in open group (P > 0.05). TEVAR patients had significantly lower crude mortality rate versus open repair (11% versus 25.2%, P < 0.005). When adjusted using O/E, the TEVAR group also had significantly less deaths versus open repair (0.40 versus 0.68, P < 0.000008). CONCLUSIONS: For BTAIs, thoracic endovascular aortic repairs were superior to open repair on injury-adjusted, all-cause mortality.


Assuntos
Aorta Torácica/lesões , Procedimentos Endovasculares/métodos , Lesões do Sistema Vascular/cirurgia , Ferimentos não Penetrantes/complicações , Adolescente , Adulto , Aorta Torácica/cirurgia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/estatística & dados numéricos , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Sistema de Registros/estatística & dados numéricos , Estudos Retrospectivos , Análise de Sobrevida , Resultado do Tratamento , Estados Unidos/epidemiologia , Lesões do Sistema Vascular/diagnóstico , Lesões do Sistema Vascular/etiologia , Lesões do Sistema Vascular/mortalidade , Adulto Jovem
3.
J Vasc Surg ; 70(3): 941-953.e13, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31445650

RESUMO

BACKGROUND: Thoracic endovascular aortic repair has transformed the management of blunt traumatic thoracic aortic injuries (BTTAI). Recent studies have suggested that the nonoperative management (NOM) of BTTAI may be a viable alternative. We investigated the NOM of BTTAI by conducting a systematic review and meta-analysis of the mortality proportions and incidence of complications. METHODS: We searched PubMed through June 22, 2017, and referenced lists of included studies without language restriction, with the assistance of a trained librarian. We included studies that reported the NOM of BTTAI (≥5 participants). Two authors independently screened titles, abstracts, and performed data extraction. Pooled prevalence of mortality (aortic related, in hospital) were obtained based on binomial distribution with Freeman-Tukey double-arcsine transformation and continuity correction. The random-effects model was used for all analyses to account for variation between studies. Meta-regression was performed to explore sources of heterogeneity, including Injury Severity Score, age, and gender. RESULTS: We included 35 studies comprising 2897 participants. The pooled prevalence of all-cause in-patient mortality in the overall, grade I, grade II, grade III, and grade IV populations are as follows: 29.0% (95% confidence interval [CI], 19.3%-39.6%; I2 = 95%; P < .01), 6.8% (95% CI, 0.6%-19.3%; I2 = 52%; P = .03), 0% (95% CI, 0%-2.0%; I2 = 0%; P = .81), 29.2% (95% CI, 17%-42.5%; I2 = 3%; P = .41), and 87.4% (95% CI, 16.4%-100%; I2 = 48%; P = .14), respectively. The combined incidence of aortic-related in-patient mortality in the overall, grade I, grade II, and grade III populations are: 2.4% (95% CI, 0.4%-5.5%; I2 = 60%; P < .01), 0.93% (95% CI, 0%-14.2%; I2 = 65%; P < .01), 0% (95% CI, 0%-1.8%; I2 = 0%; P = .99), and 0.13% (95% CI, 0%-6.4%; I2 = 14%; P = .33), respectively. The total proportion of postdischarge aortic-related mortality is 0% (95% CI, 0%-0.5%; I2 = 0%; P = .91). Meta-regression showed a decreased risk of in-hospital mortality as age increases (ß = .99; 95% CI, 0.98-1.00), an increased risk of in-hospital mortality with a higher Injury Severity Score (ß = 1.02; 95% CI, 1.00-1.04), and a decreased risk of in-hospital mortality among male patients (ß = .54; 95% CI, 0.3-0.90). CONCLUSIONS: This study provides, to our knowledge, the most up-to-date pooled estimate of mortality rates after the NOM of BTTAI. However, its interpretation is limited by the paucity of data and substantial quantitative heterogeneity. If patients are to be managed nonoperatively, we would recommend the judicious use of active surveillance in a select group of patients in the short, mid, and long term.


Assuntos
Aorta Torácica/lesões , Procedimentos Endovasculares , Traumatismos Torácicos/terapia , Lesões do Sistema Vascular/terapia , Ferimentos não Penetrantes/terapia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Aorta Torácica/diagnóstico por imagem , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Mortalidade Hospitalar , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Prevalência , Medição de Risco , Fatores de Risco , Traumatismos Torácicos/diagnóstico por imagem , Traumatismos Torácicos/mortalidade , Resultado do Tratamento , Lesões do Sistema Vascular/diagnóstico por imagem , Lesões do Sistema Vascular/mortalidade , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos não Penetrantes/mortalidade , Adulto Jovem
4.
S Afr J Surg ; 57(3): 30-37, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31392862

RESUMO

BACKGROUND: Major pancreatic injuries are complex to treat, especially when combined with vascular and other critical organ injuries. This case-matched analysis assessed the influence of associated visceral vascular injuries on outcome in pancreatic injuries. METHOD: A registered prospective database of 461 consecutive patients with pancreatic injuries was used to identify 68 patients with a Pancreatic Injury combined with a major visceral Vascular Injury (PIVI group) and were matched one-to-one by an independent blinded reviewer using a validated individual matching method to 68 similar Pancreatic Injury patients without a vascular injury (PI group). The two groups were compared using univariate and multivariate logistic regression analysis and outcome including complication rates, length of hospital stay and 90-day mortality rate was measured. RESULTS: The two groups were well matched according to surgical intervention. Mortality in the PIVI group was 41% (n = 28) compared to 13% (n = 9) in the PI alone group (p = 0.000, OR 4.5, CI 1.00-10.5). On univariate analysis the PIVI group was significantly more likely to (i) be shocked on admission, (ii) have a RTS < 7.8, (iii) require damage control laparotomy, (iv) require a blood transfusion, both in frequency and volume, (v) develop a major postoperative complication and (vi) die. On multivariate analysis, the need for damage control laparotomy was a significant variable (p = 0.015, OR 7.95, CI 1.50-42.0) for mortality. Mortality of AAST grade 1 and 2 pancreatic injuries combined with a vascular injury was 18.5% (5/27) compared to an increased mortality of 56.1% (23/41) of AAST grade 3, 4 and 5 pancreatic injuries with vascular injuries (p = 0.0026). CONCLUSION: This study confirms that pancreatic injuries associated with major visceral vascular injuries have a significantly higher complication and mortality rate than pancreatic injuries without vascular injuries and that the addition of a vascular injury with an increasing AAST grade of pancreatic injury exponentially compounds the mortality rate.


Assuntos
Pâncreas/lesões , Pâncreas/cirurgia , Sistema Porta/lesões , Lesões do Sistema Vascular/complicações , Lesões do Sistema Vascular/mortalidade , Traumatismos Abdominais/complicações , Traumatismos Abdominais/mortalidade , Traumatismos Abdominais/cirurgia , Adolescente , Adulto , Idoso , Aorta/lesões , Transfusão de Sangue , Estudos de Casos e Controles , Feminino , Humanos , Tempo de Internação , Masculino , Artéria Mesentérica Superior/lesões , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Artéria Renal/lesões , Veias Renais/lesões , Choque/etiologia , Artéria Esplênica/lesões , Taxa de Sobrevida , Índices de Gravidade do Trauma , Lesões do Sistema Vascular/cirurgia , Veia Cava Inferior/lesões , Adulto Jovem
5.
Vasc Endovascular Surg ; 53(7): 541-546, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31248345

RESUMO

BACKGROUND: The aim of this study is to present the experience of a Vascular Division at a Hellenic University hospital concerning the management of iatrogenic vascular injuries (IVIs) of the abdomen or pelvis. PATIENTS AND METHODS: This is a retrospective study evaluating all IVIs reported during a 10-year period in our institution. Only injuries warranting a vascular surgeon consultation were included in the study. Non-iatrogenic injuries were not included. Mortality and major complications within 30 days were evaluated. RESULTS: Overall, 70 cases were recorded, with 41% being venous and 59% being arterial injuries. Iliac arteries (51%) were the most common location and rupture/lacerations (73%) were the most common type of injury. General surgery (61.5%) and cardiology (30%) procedures were the most frequently involved procedures. A 30-day mortality was 5.7%, with 30% of cases treated conservatively. Synthetic bypass grafting (odds ratio [OR] = 65.0; 95% confidence interval [CI], 4.022-1050.358; P = .003) and male gender (OR = 83.77; 95% CI, 4.040-1736.738; P = .004) were associated with death. CONCLUSIONS: Iatrogenic vascular injuries of the abdomen or pelvis are usually associated with general surgery and endovascular procedures. When vascular consultation is requested early, mortality could remain low. However, a selected number of stable patients with retroperitoneal or pelvic hematomas could be treated conservatively, yielding satisfying results.


Assuntos
Abdome/irrigação sanguínea , Hospitais Universitários , Doença Iatrogênica , Pelve/irrigação sanguínea , Procedimentos Cirúrgicos Vasculares , Lesões do Sistema Vascular/cirurgia , Angiografia Digital , Angiografia por Tomografia Computadorizada , Feminino , Grécia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Fatores de Tempo , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/mortalidade , Lesões do Sistema Vascular/diagnóstico por imagem , Lesões do Sistema Vascular/etiologia , Lesões do Sistema Vascular/mortalidade
6.
J Surg Res ; 242: 94-99, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31071610

RESUMO

BACKGROUND: Traumatic superior mesenteric vein (SMV) injury is rare, and the ideal treatment is controversial. We compared the outcomes of ligation versus repair of SMV injury using the National Trauma Databank. MATERIALS AND METHODS: All adult patients who suffered from traumatic SMV injury were identified from the National Trauma Databank (2002-2014) by International Classification of Diseases (ICD) codes. Patients were stratified by treatment modality into no repair, ligation, and surgical repair using ICD procedure codes. Patient characteristics were compared between ligation and surgical repair groups using the Kruskal-Wallis test for continuous variables and Fisher's exact test for categorical variables. Outcomes, including mortality, rates of small bowel resection, length of stay (LOS), and ventilation days were compared using logistic regression. RESULTS: Among 952 patients with SMV injury, 192 patients (20.2%) had ligation, 428 (50%) underwent surgical repair, and 332 patients (34.9%) had neither repair nor ligation of the SMV. Overall hospital mortality was 32%. Age, gender, injury severity score (ISS), and Glasgow Coma Scale (GCS) were similar between groups that underwent ligation and surgical repair. Although the mortality rate (29.4% versus 36.5%, P = 0.20) and bowel resection rate (4% versus 3%, P = 0.12) were similar, patients who underwent repair had significantly longer hospital LOS (19.4 ± 24.8 versus15.2 ± 24.4 d, P < 0.001) and ICU LOS (13 ± 17.1 versus 9.3 ± 11.8 d, P = 0.02) compared to ligation. Similar results were observed in multivariable analysis when adjusted for race, associated vascular injuries, and other associated injuries. CONCLUSIONS: In patients with traumatic SMV injury, surgical repair does not appear to confer a significant survival advantage over ligation and can be associated with greater LOS and ICU LOS. Ligation may be an acceptable option for management of a traumatic SMV injury, especially when surgical repair cannot be performed, without compromising patient mortality or bowel resection rates.


Assuntos
Unidades de Terapia Intensiva/estatística & dados numéricos , Ligadura/efeitos adversos , Veias Mesentéricas/lesões , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Lesões do Sistema Vascular/cirurgia , Adulto , Bases de Dados Factuais , Feminino , Escala de Coma de Glasgow , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Tempo de Internação/estatística & dados numéricos , Ligadura/estatística & dados numéricos , Masculino , Veias Mesentéricas/cirurgia , Pessoa de Meia-Idade , Estudos Prospectivos , Estudos Retrospectivos , Fatores de Risco , Análise de Sobrevida , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/estatística & dados numéricos , Lesões do Sistema Vascular/diagnóstico , Lesões do Sistema Vascular/mortalidade , Adulto Jovem
7.
J Vasc Surg ; 69(5): 1524-1531.e1, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-31010517

RESUMO

OBJECTIVE: Firearm injuries have high morbidity and mortality. Presentation of injuries requiring concurrent vascular repair and its outcomes are unclear. Our study's objective was to characterize the injury details and to assess the associated mortality and morbidity after vascular repair. METHODS: The National Inpatient Sample was queried from 1993 to 2014 for all firearm injuries. International Classification of Diseases, Ninth Revision codes were used to identify firearm injuries and those who also underwent a vascular repair. Multivariable analysis was used to assess the effect of a concurrent vascular repair on outcomes. RESULTS: There were 648,662 firearm injuries identified; 63,973 (9.9%) involved a vascular repair. Overall, 88.7% of patients were male, and Medicaid was the most common insurance (40.2%). Intents were assault or legal intervention (60%), unintentional (24.2%), and suicide (8.6%). Patients undergoing vascular repair were younger, more often of black race and male sex, and on Medicaid insurance, with a lower household income and assault/legal intent (P < .005). Patients who underwent vascular repair had a higher frequency of abdomen/pelvis and extremity injuries as well as an elevated New Injury Severity Score (P < .005). Patients with vascular repair were more frequently treated at urban, teaching, and large hospitals (P < .005). Overall mortality rate was 2.2%; patients who underwent vascular repair had a higher mortality compared with those without (5.51% vs 1.98%; P < .001). Patients with vascular repair had higher rates of acute renal failure (3.1% vs 0.8%), venous thromboembolic events (0.5% vs 0.3%), pulmonary-related events (0.6% vs 0.28%), cardiac-related events (0.8% vs 0.2%), sepsis (1.4% vs 0.5%), and any complication (5.7% vs 2%; all P < .0001). Vascular repair was independently associated with mortality (odds ratio [OR], 2.68; 95% confidence interval [CI], 2.43-2.95; P < .0001). Age older than 46 years (OR, 2.01; 95% CI, 1.71-2.35; P < .0001), male sex (OR, 1.15; 95% CI, 1.05-1.25; P = .003), self-pay/no insurance (OR, 1.6; 95% CI, 1.47-1.75; P < .0001), suicide intent (OR, 3.73; 95% CI, 3.36-4.13; P < .0001), unintentional intent (OR, 1.12; 95% CI, 1.03-1.22; P < .0001), head/neck location (OR, 13.9; 95% CI, 12.5-15.6; P < .0001), Northeast region, and New Injury Severity Score >4 were independently associated with in-hospital mortality. Vascular repair was also independently associated with any complication (OR, 2.12; 95% CI, 1.98-2.28; P < .0001). CONCLUSIONS: Firearm injuries with vascular repair were independently associated with higher injury severity score and mortality. A majority of vascular repairs were performed for injury to the abdomen/pelvis and extremity with assault/legal intent, whereas head and neck injury and suicide intent were the least frequent.


Assuntos
Armas de Fogo , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Lesões do Sistema Vascular/cirurgia , Ferimentos por Arma de Fogo/cirurgia , Adolescente , Adulto , Criança , Pré-Escolar , Bases de Dados Factuais , Feminino , Mortalidade Hospitalar , Humanos , Incidência , Lactente , Recém-Nascido , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Procedimentos Cirúrgicos Vasculares/mortalidade , Lesões do Sistema Vascular/diagnóstico , Lesões do Sistema Vascular/mortalidade , Ferimentos por Arma de Fogo/diagnóstico , Ferimentos por Arma de Fogo/mortalidade , Adulto Jovem
8.
Vasc Endovascular Surg ; 53(6): 477-487, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30991899

RESUMO

OBJECTIVE: To review the current use of endovascular techniques in trauma. SUMMARY BACKGROUND DATA: Multiple studies have demonstrated that, despite current guidelines, endovascular therapies are used in instances of arterial trauma. METHODS: The existing literature concerning arterial trauma was reviewed. Studies reviewed included case reports, single-center case series, large database studies, official industry publications and instructions for use, and society guidelines. RESULTS: Endovascular therapies are used in arterial trauma in all systems. The use of thoracic endografts in blunt thoracic aortic trauma is accepted and endorsed by society guidelines. The use of endovascular therapies in other anatomic locations is largely limited to single-center studies. Advantages potentially include less morbidity due to smaller incisions as well as shorter operating room times. Many report using endovascular therapies even with hard signs of injury. Long-term results are limited by a lack of long-term follow-up but, in general, suggest that these techniques produce acceptable outcomes. The adoption of these techniques may be limited by resource and surgeon availability. CONCLUSIONS: The use of endovascular therapies in trauma has gained acceptance despite not yet having a place in official guidelines.


Assuntos
Artérias/cirurgia , Implante de Prótese Vascular , Procedimentos Endovasculares , Lesões do Sistema Vascular/cirurgia , Artérias/diagnóstico por imagem , Artérias/lesões , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Humanos , Fatores de Risco , Resultado do Tratamento , Lesões do Sistema Vascular/diagnóstico por imagem , Lesões do Sistema Vascular/mortalidade
9.
J Cardiovasc Surg (Torino) ; 60(3): 289-297, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30855117

RESUMO

Blunt thoracic aortic injury (BTAI) represents an infrequently encountered but lethal traumatic injury. Minimal aortic injuries are appropriately treated by medical management, while more severe injuries require endovascular or open repair. Rapidly evolving endovascular technology has largely supplanted open repair as first line operative intervention, however, the complexity of the severely injured blunt trauma patient can complicate management decisions. The development and implementation of an optimal consensus grading system and treatment algorithm for the management of BTAI is necessary and will require multi-institutional study.


Assuntos
Aorta Torácica/cirurgia , Implante de Prótese Vascular , Tomada de Decisão Clínica , Procedimentos Endovasculares , Seleção de Pacientes , Traumatismos Torácicos/cirurgia , Lesões do Sistema Vascular/cirurgia , Ferimentos não Penetrantes/cirurgia , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/lesões , Aortografia/métodos , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Angiografia por Tomografia Computadorizada , Procedimentos Endovasculares/efeitos adversos , Humanos , Fatores de Risco , Traumatismos Torácicos/diagnóstico por imagem , Traumatismos Torácicos/mortalidade , Resultado do Tratamento , Ultrassonografia de Intervenção , Lesões do Sistema Vascular/diagnóstico por imagem , Lesões do Sistema Vascular/mortalidade , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos não Penetrantes/mortalidade
10.
Vascular ; 27(2): 213-223, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30739602

RESUMO

INTRODUCTION: Blunt traumatic thoracic aortic injury, the second leading cause of death from trauma, poses unique challenges in its management. However, there has not yet been a corresponding consolidated series of outcomes reported in Asia, which this systematic review aims to address. METHOD: This review was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Searches were performed on MEDLINE, EMBASE, Google Scholar, and Cochrane Database for studies performed in Asia reporting the endovascular management of blunt traumatic thoracic aortic injury. Risk of bias was assessed using the Newcastle-Ottawa scale. Meta-analyses of pooled proportions were performed using the metaprop command in STATA. This review has been prospectively registered in PROSPERO (CRD42018083773). RESULTS: Sixteen retrospective cohort studies were included, reporting a total of 238 patients. The pooled Injury Severity Score was 32.5 (95%CI 27.8-37.1). The pooled mean time to operation from diagnosis was 39.2 hours (95%CI 24.6-53.8 hours), and operation time was 100 min (95%CI 63.5-136.5 min). The pooled rate of procedural conversion from endovascular repair to open surgery was 0.17% (95%CI 0-3.7%), and the proportion of left subclavian artery coverage was 55% (95%CI 37-72%). The pooled prevalence of intra-operative all-cause and aortic-related mortality was 0.72% (95%CI 0-4.9%) and 0.27% (95%CI 0-3.8%), respectively. The pooled prevalence of 30-day all-cause and aortic-related mortality was 2.2% (95%CI 0.16-5.6%) and 2.1% (95%CI 0-3.7%), respectively. In terms of 30-day complication, the pooled prevalence rates of type 1 endoleak, endograft complications, vascular access injury, strokes, and aortic re-rupture were 1.2%, 0.34%, 0.14%, 0.02%, and 0.01%, respectively. There were no cases of types II and III endoleak, and renal failure. CONCLUSION: Short- to mid-term results for thoracic endovascular aortic repair for blunt traumatic thoracic aortic injury in Asia are encouraging. However, there is a distinct disparity in reporting across Asia. We propose a prospective database for outcome reporting post thoracic endovascular aortic repair in this patient population, and ongoing follow up to assess long-term efficacy of this treatment strategy.


Assuntos
Aorta Torácica/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Procedimentos Endovasculares/instrumentação , Traumatismos Torácicos/cirurgia , Lesões do Sistema Vascular/cirurgia , Ferimentos não Penetrantes/cirurgia , Adulto , Idoso , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/lesões , Ásia/epidemiologia , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Desenho de Prótese , Fatores de Risco , Traumatismos Torácicos/diagnóstico por imagem , Traumatismos Torácicos/mortalidade , Resultado do Tratamento , Lesões do Sistema Vascular/diagnóstico por imagem , Lesões do Sistema Vascular/mortalidade , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos não Penetrantes/mortalidade , Adulto Jovem
11.
J Vasc Surg ; 69(6): 1704-1709, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30792055

RESUMO

OBJECTIVE: Routine computed tomography (CT) imaging in trauma patients has led to increased recognition of blunt vertebral artery injuries (BVIs). We sought to determine the prevalence of strokes, injury progression, and need for intervention in patients with BVI. METHODS: Consecutive patients presenting with BVI during 2 years were identified from the institutional trauma registry. Inpatient records, imaging studies, and follow-up data were reviewed in detail from the electronic medical record. RESULTS: There were 76 BVIs identified in 70 patients (64% male; mean age, 47 ± 19 years); bilateral injuries occurred in 6 patients. Five patients who arrived at the hospital intubated had evidence of posterior circulation infarcts on admission CT, whereas one additional patient had evidence of a posterior circulation infarct attributed to complications of late spinal surgery. Four of the five patients with infarcts on admission CT survived to discharge, but only one had residual stroke symptoms. Minor (grade 1 or grade 2) injuries occurred in 25 (36%) patients; severe (grade 3 or grade 4) injuries occurred in 45 (64%). Twelve patients died of associated injuries (eight with severe BVI, four with minor BVI). Stepwise logistic regression analysis selected age (odds ratio, 1.14; confidence interval, 1.04-1.25; P < .001) and intubation on arrival (odds ratio, 450.4; confidence interval, 17.41-1645.51; P < .001) as independent predictors of hospital stroke and death. Of the 58 surviving to discharge, 31 (53%) returned for follow-up CT scans. Six of 10 (60%) patients with minor injuries had resolution or improvement compared with 3 of 21 (14%) with severe injuries (P = .027). One patient (10%) with a minor BVI and two patients (10%) with severe BVI had radiologic progression, but none were clinically significant. During a mean follow-up of 15 ± 13 months, none of the study patients had treatment (surgical or interventional) for BVI, and there were no delayed strokes. Only five patients in this series had vertebral pseudoaneurysms, which limits conclusions about this type of BVI. CONCLUSIONS: These data suggest that BVI-related strokes are present at the time of admission and do not have clinical sequelae. No late strokes occurred in this series, and no surgical or interventional treatments were required even in the presence of radiographic worsening. The relatively few cases of vertebral pseudoaneurysms in this series limit any conclusions about these specific lesions. However, these data indicate that follow-up imaging of nonaneurysmal BVI is not necessary in adults who are found to be asymptomatic on follow-up.


Assuntos
Angiografia por Tomografia Computadorizada , Procedimentos Desnecessários , Lesões do Sistema Vascular/diagnóstico por imagem , Dissecação da Artéria Vertebral/diagnóstico por imagem , Artéria Vertebral/diagnóstico por imagem , Ferimentos não Penetrantes/diagnóstico por imagem , Adulto , Idoso , Doenças Assintomáticas , Bases de Dados Factuais , Progressão da Doença , Registros Eletrônicos de Saúde , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prevalência , Prognóstico , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/mortalidade , Lesões do Sistema Vascular/mortalidade , Lesões do Sistema Vascular/terapia , Artéria Vertebral/lesões , Dissecação da Artéria Vertebral/mortalidade , Dissecação da Artéria Vertebral/terapia , Ferimentos não Penetrantes/mortalidade , Ferimentos não Penetrantes/terapia
12.
Ann Vasc Surg ; 59: 150-157, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30802562

RESUMO

BACKGROUND: Blunt thoracic aortic injury (BTAI) occurs in <1% of all trauma admissions. Thoracic endovascular aortic repair (TEVAR) has become the preferred treatment modality in adult patients with BTAI, but its use in pediatrics is currently not supported by device manufacturers and lacks United States Food and Drug Administration approval. We hypothesized that there would also be an increased use of TEVAR in the pediatric population, thus conferring a lower risk of mortality compared with open thoracic aortic repair (OTAR). METHODS: The National Trauma Data Bank (2007-2015) was queried for patients ≤17 years with BTAI. The primary outcomes were the incidences of TEVAR and OTAR. Secondary outcome was risk of mortality in those undergoing intervention. A multivariable logistic regression model was used to determine the risk of mortality in OTAR versus TEVAR. RESULTS: We identified 650 pediatric BTAI patients with 159 (24.5%) undergoing intervention. Of these, 124 underwent TEVAR (78.0%) and 35 (22.0%) underwent OTAR. The rate of TEVAR steadily increased from 2007 to 2015 (15.4% vs. 27.1%, P < 0.001). Patients receiving OTAR and TEVAR had a similar injury severity score and rate of hypotension on admission (P > 0.05). Compared with OTAR, TEVAR patients had a higher rate of any traumatic brain injury (TBI) (63.7% vs. 37.1%, P = 0.005) and shorter hospital and intensive care unit length of stay (LOS) (16.4 vs. 21.4 days, P = 0.02; 10.1 vs. 12.2 days, P = 0.01). TEVAR and OTAR, even when stratified by ≤14 years and 15-17 years, had no difference in risk for mortality (odds ratio 1.20, confidence interval 0.29-5.01, P = 0.80). CONCLUSIONS: The rate of TEVAR in pediatric BTAI nearly doubled from 2007 to 2015. Compared with OTAR, TEVAR was associated with a shorter hospital LOS despite a higher rate of TBI. There was no difference in risk for mortality between TEVAR and OTAR. Longitudinal studies to determine the long-term efficacy and complication rates, including reintervention, development of endoleak, and/or need for further operations, are needed as this technology is being rapidly adopted for pediatric trauma patients.


Assuntos
Aorta Torácica/cirurgia , Implante de Prótese Vascular/tendências , Procedimentos Endovasculares/tendências , Traumatismos Torácicos/cirurgia , Lesões do Sistema Vascular/cirurgia , Ferimentos não Penetrantes/cirurgia , Adolescente , Idade de Início , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/lesões , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Bases de Dados Factuais , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Humanos , Incidência , Tempo de Internação , Masculino , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/terapia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Traumatismos Torácicos/diagnóstico por imagem , Traumatismos Torácicos/mortalidade , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Lesões do Sistema Vascular/diagnóstico por imagem , Lesões do Sistema Vascular/mortalidade , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos não Penetrantes/mortalidade
13.
Vascular ; 27(2): 204-212, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30522411

RESUMO

BACKGROUND: Whilst the management of blunt traumatic thoracic aortic injury has seen a paradigm shift to an 'endovascular first' approach, the limitations of thoracic endovascular aortic repair remain. An inadequate proximal landing zone limits the use of thoracic aortic stent grafts and in an emergent polytrauma setting, aortic arch debranching via open surgery may not be practical or feasible. A wholly endovascular approach to debranching utilising 'off-the-shelf' stents and parallel graft techniques may represent a possible solution. Hence, we sought to perform a systematic review investigating the use of chimney graft techniques alongside thoracic aortic stenting in blunt traumatic thoracic aortic injury. METHODS: We performed the systematic review in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Searches were performed on Medline (PubMed), Web of Science and Scopus to identify articles describing the use of chimney grafts in traumatic aortic transection (PROSPERO: CRD42017082549). RESULTS: The systematic search revealed 172 papers, of which 88 duplicates were removed resulting in 84 papers to screen. Based on title, abstract and full text review, six articles were included for final analysis. There were nine patients in total with an average age of 41 (three females, five males, one unspecified), all with significant polytrauma, secondary to the mechanism of injury. A variety of stents were used between centres, with techniques showing a predominance to stenting of the left subclavian artery (77%, n = 7). The technical success rate was 82%, with two (18%) cases of type 1 endoleaks, of which one resolved spontaneously. CONCLUSIONS: Despite the encouraging results, this by no means provides for a firm conclusion given the small sample size. Patients should still be judiciously selected on a case-by-case basis when employing the chimney graft technique. Larger cohort studies are needed to establish these findings.


Assuntos
Aorta Torácica/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Procedimentos Endovasculares/instrumentação , Traumatismos Torácicos/cirurgia , Lesões do Sistema Vascular/cirurgia , Ferimentos não Penetrantes/cirurgia , Adulto , Idoso , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/lesões , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Desenho de Prótese , Fatores de Risco , Traumatismos Torácicos/diagnóstico por imagem , Traumatismos Torácicos/mortalidade , Resultado do Tratamento , Lesões do Sistema Vascular/diagnóstico por imagem , Lesões do Sistema Vascular/mortalidade , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos não Penetrantes/mortalidade
14.
Injury ; 50(1): 137-141, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30509568

RESUMO

INTRODUCTION: Abdominal vascular injuries (AVIs) remain a great challenge since they are associated with significant mortality. Penetrating injury is the most common cause of AVIs; however, some AVI series had more blunt injuries. There is little information regarding differences between penetrating and blunt AVIs. The objective of the present study was to identify the differences between these two mechanisms in civilian AVI patients in terms of patient's characteristics, injury details, and outcomes. METHOD: From January 2007 to January 2016, we retrospectively collected the data of AVI patients at King Chulalongkorn Memorial hospital, including demographic data, details of injury, the operative managements, and outcomes in terms of morbidity and mortality. The comparison of the data between blunt and penetrating AVI patients was performed. RESULTS: There were 55 AVI patients (28 blunt and 27 penetrating). Majority (78%) of the patients in both groups were in shock on arrival. Blunt AVI patients had significantly higher injury severity score (mean(SD) ISS, 36(20) vs. 25(9), p = 0.019) and more internal iliac artery injuries (8 vs. 1, p = 0.028). On the other hand, penetrating AVI patients had more aortic injuries (5 vs. 0, p = 0.046), and inferior vena cava injuries (7 vs. 0, p = 0.009). Damage control surgery (DCS) was performed in 45 patients (82%), 25 in blunt and 20 in penetrating. The overall mortality rate was 40% (50% in blunt vs. 30% in penetrating, p = 0.205). CONCLUSIONS: Blunt AVI patients had higher ISS and more internal iliac artery injuries, while penetrating AVI patients had more aortic injuries and vena cava injuries. Majority of AVI patients in both groups presented with shock and required DCS.


Assuntos
Traumatismos Abdominais/fisiopatologia , Embolização Terapêutica/métodos , Centros de Traumatologia , Lesões do Sistema Vascular/fisiopatologia , Ferimentos não Penetrantes/fisiopatologia , Ferimentos Penetrantes/fisiopatologia , Traumatismos Abdominais/diagnóstico , Traumatismos Abdominais/mortalidade , Traumatismos Abdominais/terapia , Adulto , Embolização Terapêutica/mortalidade , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida , Tailândia/epidemiologia , Resultado do Tratamento , Lesões do Sistema Vascular/mortalidade , Lesões do Sistema Vascular/terapia , Ferimentos não Penetrantes/diagnóstico , Ferimentos não Penetrantes/mortalidade , Ferimentos não Penetrantes/terapia , Ferimentos Penetrantes/diagnóstico , Ferimentos Penetrantes/mortalidade , Ferimentos Penetrantes/terapia , Adulto Jovem
15.
J Formos Med Assoc ; 118(1 Pt 2): 305-310, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29859848

RESUMO

PURPOSE: To evaluate the incidence, risk factors, mortality, and complications of direct vascular injury (VI) in patients who underwent primary total knee arthroplasty (TKA) using data from a nationwide database. METHODS: Data were collected from the National Health Insurance Research Database of Taiwan. The study group included 111,497 patients who underwent TKA from January 2004 to December 2011. In total, 15 cases of direct VI were reported (VI group). We analyzed the incidence, risk factors, mortality, complications of direct VI and hospital stays between groups (VI group and non-VI group). RESULTS: Average incidence of VI was 13.74 per 100,000 person-years. No patient-dependent risk factors for VI were identified. Surgeons with low surgical volume highly correlated with incidence of VI (P < 0.05). 90-day mortality was significantly higher (33.3% vs. 0.37%) and length of hospital stay was significantly longer (19.43 days vs. 7.26 days) in the VI group than in the control group. In addition, incidence of periprosthetic joint infection, restenosis at the injury site, and limb loss were significantly higher in the VI group than in the control group. CONCLUSION: VI during primary TKA was associated with significantly higher incidence of periprosthetic joint infection, restenosis at the injury site, and limb loss, as well as higher 90-day mortality. Therefore, surgeons should be aware of VI during primary TKA, especially those with low surgical volume.


Assuntos
Artroplastia do Joelho/efeitos adversos , Tempo de Internação/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Lesões do Sistema Vascular/etiologia , Idoso , Artrite Infecciosa/epidemiologia , Artroplastia do Joelho/mortalidade , Feminino , Humanos , Incidência , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Taiwan/epidemiologia , Lesões do Sistema Vascular/mortalidade
16.
Vascular ; 27(3): 252-259, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30426848

RESUMO

OBJECTIVE: Axillosubclavian vessel injury is rare, with most cases occurring after penetrating trauma. A prior database (2002-2006) analysis demonstrated an overall limb loss rate of 2.9%, with no difference between isolated arterial axillosubclavian vessel injury and combined artery/vein axillosubclavian vessel injury. Given increases in advanced vascular surgical techniques, as well as improved multidisciplinary care and expeditious diagnosis with computed tomography angiography, we hypothesized the national rate of limb loss in patients with arterial axillosubclavian vessel injury has decreased. In addition, we attempted to identify current predictors for limb loss in arterial axillosubclavian vessel injury. Finally, we hypothesized that combined artery/vein axillosubclavian vessel injury, as well as associated brachial plexus injury will have a higher risk for limb-loss and mortality compared to isolated arterial axillosubclavian vessel injury. METHODS: A retrospective analysis of the National Trauma Data Bank was performed between 2007 and 2015. All patients ≥ 18 years of age with arterial axillosubclavian vessel injury were included. The primary outcome was limb loss. After a univariable logistic regression model identified significant covariates, we performed a multivariable logistic regression for analysis. RESULTS: Of the total 5,494,609 trauma admissions, 3807 patients had arterial axillosubclavian vessel injury (<0.1%). Of these, 3137 (82.4%) had isolated arterial axillosubclavian vessel injury and 670 (17.6%) had combined artery/vein axillosubclavian vessel injury. The overall limb loss rate was 2.4% (from 2.9% in 2006, p = 0.47). After adjusting for covariates, independent risk factors for limb loss included a combined artery/vein axillosubclavian vessel injury (odds ratio = 3.54, confidence interval = 2.06-6.11, p < 0.001), blunt mechanism (odds ratio = 7.81, confidence interval = 4.21-14.48, p < 0.001), open repair (odds ratio = 2.37, confidence interval = 1.47-3.82, p < 0.001), and open proximal humerus fracture (odds ratio = 8.50, confidence interval = 4.97-14.54, p < 0.001). An associated brachial plexus injury was not associated with limb loss ( p = 0.37). Combined artery/vein axillosubclavian vessel injury was associated with higher risk for mortality compared to isolated arterial axillosubclavian vessel injury (odds ratio = 2.17, confidence interval = 1.73-2.71, p < 0.001). CONCLUSIONS: The national rate of limb loss in trauma patients with arterial axillosubclavian vessel injury has not changed in the past decade. A combined artery/vein axillosubclavian vessel injury is an independent risk factor for limb loss, as well as open repair. However, the strongest risk factor is an open proximal humerus fracture. An associated brachial plexus injury is not associated with increased risk of limb loss. Patients with combined artery/vein axillosubclavian vessel injury have a twofold increased risk of death compared to patients with isolated arterial axillosubclavian vessel injury.


Assuntos
Amputação , Artéria Axilar/lesões , Fraturas do Úmero/epidemiologia , Traumatismo Múltiplo/epidemiologia , Artéria Subclávia/lesões , Lesões do Sistema Vascular/epidemiologia , Veias/lesões , Adulto , Amputação/efeitos adversos , Amputação/mortalidade , Artéria Axilar/diagnóstico por imagem , Artéria Axilar/cirurgia , Angiografia por Tomografia Computadorizada , Bases de Dados Factuais , Procedimentos Endovasculares , Feminino , Humanos , Fraturas do Úmero/diagnóstico , Fraturas do Úmero/mortalidade , Fraturas do Úmero/cirurgia , Salvamento de Membro , Masculino , Pessoa de Meia-Idade , Traumatismo Múltiplo/diagnóstico , Traumatismo Múltiplo/mortalidade , Traumatismo Múltiplo/cirurgia , Estudos Retrospectivos , Fatores de Risco , Artéria Subclávia/diagnóstico por imagem , Artéria Subclávia/cirurgia , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Lesões do Sistema Vascular/diagnóstico , Lesões do Sistema Vascular/mortalidade , Lesões do Sistema Vascular/cirurgia , Veias/diagnóstico por imagem , Veias/cirurgia , Adulto Jovem
17.
Ann Vasc Surg ; 56: 36-45, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30500659

RESUMO

BACKGROUND: Firearm injuries can be morbid and potentially have high resource utilization. Historically, trauma and vascular surgery patients are at higher risk for readmissions. Our goal was to assess the risk for readmission among patients undergoing vascular repair after a firearm injury. METHODS: The National Readmission Database was queried from 2011 to 2014. All firearm injuries with or without vascular repair were analyzed. Multivariable analysis was conducted to assess the effect of concurrent vascular repair on readmissions at 30, 90, and 180 days. RESULTS: There were 42,184 firearm injury admissions identified, where 93.3% did not undergo vascular repair and 6.7% required vascular repair. The overall in-hospital death rate was 8.2%. Average age was 29.9 ± 0.2 years, and 89.2% were male. Intent was most frequently assault (61.2%) followed by unintentional injury (26.5%), suicide (5.2%), and legal intervention (3.1%). Patients with vascular repair compared to those without vascular repair were more frequently admitted at teaching hospitals (85.2% vs. 81.8%, P = 0.042), had higher Agency for Healthcare Research and Quality (AHRQ) extreme severity of illness, AHRQ risk of mortality, New Injury Severity Score (NISS), and had more diagnoses and procedures (P < 0.0001). Patients with vascular repair compared to those without vascular repair also more frequently sustained abdominal/pelvis injury (40.4% vs. 23.4%, P < 0.0001) and were more likely to have anemia (5.9% vs. 3.6%, P = 0.009). Patients undergoing vascular repair had a higher rate for 30-day (8.9% vs. 5.5%, P = 0.0001), 90-day (18.1% vs 9.5%, P < 0.0001), and 180-day (22.3% vs. 13%, P < 0.0001) readmission. Kaplan-Meier analysis of unadjusted data showed a higher readmission rate over time with vascular repair. Multivariable analysis demonstrated that vascular repair was not associated with higher 30-day readmission (odds ratio [OR] 1.26, 95% confidence interval [CI] 0.92-1.72, P = 0.14) but was for 90-day (OR 1.38, 95% CI 1.14-1.68, P = 0.001) and 180-day readmission (OR 1.24, 95% CI 1.06-1.45, P = 0.009). Additional factors associated with 30-day readmission were higher NISS, discharge to a care facility, and Elixhauser score. Other factors associated with 90-day readmission were unintentional intent of injury, NISS, discharge to a care facility, and Elixhauser score. Factors also associated with 180-day readmission were insurance type, unintentional intent of injury, NISS, care facility discharge, and Elixhauser score. CONCLUSIONS: Firearm injury resulting in vascular injury was associated with increased readmissions at 90 and 180 days. This study establishes baseline rates for readmission after vascular repair for firearm traumas and allows opportunity for improvement through targeted interventions for these patients. Vascular surgeons can have a more active role in managing this high-profile public health issue.


Assuntos
Armas de Fogo , Readmissão do Paciente , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Lesões do Sistema Vascular/cirurgia , Ferimentos por Arma de Fogo/cirurgia , Adulto , Bases de Dados Factuais , Feminino , Humanos , Masculino , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Procedimentos Cirúrgicos Vasculares/mortalidade , Lesões do Sistema Vascular/diagnóstico , Lesões do Sistema Vascular/mortalidade , Ferimentos por Arma de Fogo/diagnóstico , Ferimentos por Arma de Fogo/mortalidade
18.
J Vasc Surg ; 69(5): 1519-1523, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30497861

RESUMO

BACKGROUND: Six hours has long been considered the threshold of ischemia after peripheral artery injury. However, there is a paucity of evidence regarding the impact of operative delays on morbidity and mortality in patients with lower extremity arterial injuries. METHODS: We analyzed the records of 3,441,259 injured patients entered into the National Trauma Data Bank Research Dataset from 2012 to 2015. Patients (≥16 years) with lower extremity arterial injuries were identified by International Classification of Diseases, Ninth Revision injury and procedure codes. Patients with crush injuries, patients with prehospital or emergency department cardiac arrest, those not transferred directly from point of injury, and patients in whom a nonoperative management strategy was attempted were excluded from analysis. RESULTS: We examined the data from 4406 patients with lower extremity arterial injuries; 85% of the patients were male, with a mean age of 35 years. The overall mortality in this cohort was 3.2% (143/4406); the amputation rate was 11.3% (499/4406). Using a multivariate logistic regression model, blunt mechanisms of injury, increased time from injury to operating room arrival, nerve injury, associated lower extremity fractures, increased age, and Injury Severity Score were associated with increased amputation risk. The amputation rate in those undergoing repair within 60 minutes was 6% compared with 11.7% and 13.4% in those undergoing repair after 1 to 3 hours and 3 to 6 hours, respectively. CONCLUSIONS: Optimal limb salvage is achieved when revascularization of lower extremity arterial injury occurs within 1 hour of injury. To improve survival and recovery after extremity arterial injury, efforts should be focused on strategies to expedite reperfusion of the injured limb.


Assuntos
Artérias/cirurgia , Extremidade Inferior/irrigação sanguínea , Tempo para o Tratamento , Procedimentos Cirúrgicos Vasculares , Lesões do Sistema Vascular/cirurgia , Adulto , Amputação , Artérias/diagnóstico por imagem , Artérias/lesões , Bases de Dados Factuais , Feminino , Humanos , Salvamento de Membro , Masculino , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/mortalidade , Lesões do Sistema Vascular/diagnóstico por imagem , Lesões do Sistema Vascular/mortalidade
19.
Ann Vasc Surg ; 56: 52-61, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30476614

RESUMO

BACKGROUND: According to the Center for Disease Control and Prevention, trauma is the leading cause of death in children aged >1 year in the United States (US). Although vascular injuries occur in only 0.6-1% of pediatric patients with trauma, they are a major mortality contributor. This study aims to examine epidemiology and outcomes after pediatric vascular injuries (PedVIs) in the US. METHODS: The National Trauma Data Bank (2002-2012) was queried to identify children (0-16) with PedVIs. Patients were categorized based on their demographics, location, and mechanism and presenting trauma severity (injury severity score [ISS] and shock). Study was divided into two 5-year periods (P1: 2002-2006; P2: 2007-2012) to study the trends in pediatric vascular trauma presentation and outcomes (hospital death and extended length of stay [LOS > 8 days]) using adjusted analyses. RESULTS: Analyses were performed on 3,408 cases; who were male (73.7%) and Caucasian (52.8%) with a mean age of 10.5 ± 4.5 years. The Southern region of the US saw the highest increase in PedVIs (P2 versus P1: 38.3% vs. 25.0%, P < 0.05). Blunt injuries constituted most of these injuries (57%). Firearm (36.9%) and motor vehicle crash (MVC) (34%) were the most common lethal mechanisms of injury. Despite the significant decrease in MVC rates (P2 versus P1: 17.4% vs. 22.6%, P < 0.05), firearm rates were unchanged. Upper extremity injuries were the most common anatomically (34.9%). ISS and shock were significantly decreased during P2. Mortality occurred in 7.9% of patients, which significantly decreased (P2 versus P1: 6.3% vs. 10.9%, P < 0.001) without a significant change in LOS. Odds of mortality decreased by 32% during P2 (P = 0.08) and was independently associated with penetrating mechanism of injury (odds ratio [OR]: 1.97; 95% confidence interval [CI]: 1.22-3.19, P = 0.006), shock at presentation (OR: 5.48; 95% CI: 3.55-8.46, P < 0.001); ISS (OR: 1.08; 95% CI: 1.06-1.27, P < 0.001), and Glasgow Coma Score < 9 (OR: 11.21; 95% CI: 7.18-17.49, P < 0.001). CONCLUSIONS: We observed a significant decrease in the overall severity of injury and in-hospital mortality concurrent with the observation of a significant decrease in the rates of pediatric MVC vascular injuries. Public health policies directed toward firearm safety may further decrease PedVIs and mortality among this vulnerable population.


Assuntos
Mortalidade Hospitalar/tendências , Tempo de Internação/tendências , Lesões do Sistema Vascular/epidemiologia , Lesões do Sistema Vascular/terapia , Adolescente , Distribuição por Idade , Causas de Morte , Criança , Pré-Escolar , Bases de Dados Factuais , Feminino , Humanos , Lactente , Recém-Nascido , Escala de Gravidade do Ferimento , Masculino , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Lesões do Sistema Vascular/diagnóstico , Lesões do Sistema Vascular/mortalidade
20.
J Cardiovasc Electrophysiol ; 30(1): 92-101, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30288838

RESUMO

INTRODUCTION: Catheter ablation (CA) has emerged as the preferred modality of treatment for many cardiac arrhythmias. Anatomical sites of ablation are often located in close proximity to coronary arteries. However, the incidence of CA-related coronary injury has not been well studied. We sought to systematically evaluate all cases of CA-related coronary injuries. METHODS AND RESULTS: A PubMed search was conducted from inception until May 1, 2017 using the keywords "coronary artery" and "ablation." We identified 2817 published articles of which 43 articles met our inclusion criteria representing 61 cases of coronary artery injury attributed to CA procedures from 1992 to 2017. Posteroseptal accessory pathway ablation was associated with the highest incidence of coronary injury (35.6% of cases), followed by cavotricuspid isthmus-dependent flutter (19.3%). The right coronary artery was the site of injury in over two-thirds of all reported cases. Coronary injury was detected intraprocedurally in about half of the cases (43.1%), whereas it was a delayed presentation in the other half. Coronary intervention was performed in a third of all cases (32.7%). There were a total of three deaths attributed to coronary artery injury. CONCLUSIONS: Most (91.8%) coronary injuries are a result of anatomic proximity to the site of ablation. Awareness of the relation between coronary artery course and anatomical site of ablation could prevent myocardial damage and improve procedural safety.


Assuntos
Arritmias Cardíacas/cirurgia , Ablação por Cateter/efeitos adversos , Vasos Coronários/lesões , Traumatismos Cardíacos/epidemiologia , Lesões do Sistema Vascular/epidemiologia , Adulto , Idoso , Arritmias Cardíacas/mortalidade , Ablação por Cateter/mortalidade , Vasos Coronários/diagnóstico por imagem , Feminino , Traumatismos Cardíacos/diagnóstico por imagem , Traumatismos Cardíacos/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Resultado do Tratamento , Lesões do Sistema Vascular/diagnóstico por imagem , Lesões do Sistema Vascular/mortalidade
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