Male kidney-specific BMAL1 knockout mice are protected from K+-deficient, high-salt diet-induced blood pressure increases.

The circadian clock protein basic helix-loop-helix aryl hydrocarbon receptor nuclear translocator-like protein 1 (BMAL1) is a transcription factor that impacts kidney function, including blood pressure (BP) control. Previously, we have shown that male, but not female, kidney-specific cadherin Cre-positive BMAL1 knockout (KS-BMAL1 KO) mice exhibit lower BP compared with littermate controls. The goal of this study was to determine the BP phenotype and immune response in male KS-BMAL1 KO mice in response to a low-K+ high-salt (LKHS) diet. BP, renal inflammatory markers, and immune cells were measured in male mice following an LKHS diet. Male KS-BMAL1 KO mice had lower BP following the LKHS diet compared with control mice, yet their circadian rhythm in pressure remained unchanged. Additionally, KS-BMAL1 KO mice exhibited lower levels of renal proinflammatory cytokines and immune cells following the LKHS diet compared with control mice. KS-BMAL1 KO mice were protected from the salt-sensitive hypertension observed in control mice and displayed an attenuated immune response following the LKHS diet. These data suggest that BMAL1 plays a role in driving the BP increase and proinflammatory environment that occurs in response to an LKHS diet.NEW & NOTEWORTHY We show here, for the first time, that kidney-specific BMAL1 knockout mice are protected from blood pressure (BP) increases and immune responses to a salt-sensitive diet. Other kidney-specific BMAL1 knockout models exhibit lower BP phenotypes under basal conditions. A salt-sensitive diet exacerbates this genotype-specific BP response, leading to fewer proinflammatory cytokines and immune cells in knockout mice. These data demonstrate the importance of distal segment BMAL1 in BP and immune responses to a salt-sensitive environment.

Spontaneous Thrombosis of an Isolated Internal Iliac Artery Aneurysm.

BACKGROUND: Isolated internal iliac artery aneurysms (IIAAs) are uncommon but potentially morbid lesions that are a challenge to monitor and treat. However, given the small numbers of reported cases and high rates of incidentally discovered lesions, the natural history of isolated IIAAs is not well characterized. This case describes an atypical and previously unreported spontaneous thrombosis of an isolated IIAA, a lesion typically thought to progressively enlarge and rupture. METHODS: Medical records and imaging studies were retrospectively reviewed with the approval of our Institutional Review Board. A single patient underwent fluoroscopic angiography followed by computed tomography (CT) angiography, with no subsequent operative intervention. RESULTS: An isolated 5.5 cm left IIAA was discovered incidentally on CT scan and subsequently seen with fluoroscopic pelvic angiography. Three weeks following initial angiography, repeat pelvic angiography and CT scan demonstrated spontaneous thrombosis of the aneurysm. CONCLUSIONS: Isolated IIAAs are conditions for which the natural history remains uncertain despite their potential risk for rupture and mortality. Spontaneous thrombosis of these lesions is possible, suggesting that the natural history as previously described warrants further consideration.

Resection of Anterior and Lateral Muscle Compartments Does Not Preclude Limb Salvage and Functions.

BACKGROUND: Fasciotomy with resection of nonviable muscle is often necessary when there is a delay in compartment syndrome (CS) diagnosis after revascularization. The reported rate of major amputation following missed CS or delayed fasciotomy ranges from 12% to 35%. Herein, the authors present a series of critically ill patients who experienced delayed CS diagnosis and required complete resection of the anterior and/or lateral compartments but still achieved limb salvage and function. METHODS: A retrospective chart review identified five patients from April 2018 to April 2019 within a single institution who met the inclusion criteria. Patient charts were reviewed for demographic data, risk factors, time to diagnosis following revascularization, muscle compartments resected, operative and wound care details, and functional outcome at follow-up. RESULTS: All of the patients developed CS of the lower extremity following revascularization secondary to acute limb ischemia and required two-incision, four-compartment fasciotomies. Further, they all required serial operative debridements to achieve limb salvage; however, there were no major amputations, and all of the patients were walking at follow-up. CONCLUSIONS: Delay in CS diagnosis can have devastating consequences, resulting in major amputation. In cases where myonecrosis is isolated to two or fewer compartments, complete compartment muscle resection can be safely performed, and limb preservation and function can be maintained with aggressive wound management and physical therapy.

Autogenous Femoral Vein for Secondary Repair of Subclavian Arteries: A Salvage Solution for Complex Clinical Scenarios.

BACKGROUND: Endovascular stent and prosthetic graft placement are commonplace techniques for correction of subclavian artery (SCA) lesions. However, when initial surgical repair of the SCA becomes complicated by subsequent infection or thrombosis of the repair site, stents and prosthetic grafts are no longer suitable for secondary repair due to the risk of recurrent failure and limited longevity. Autogenous tissue is more resistant to infection and has improved long-term patency, and thus may be a better option for secondary reconstruction in these complex clinical scenarios. The most commonly used autogenous conduit for SCA reconstruction is the great saphenous vein; however, the significant size mismatch makes this unsuitable in many circumstances. The autogenous femoral vein is a promising alternative conduit for SCA repair. Here we present 3 successful cases of its use as a salvage technique following iatrogenic complications of prior surgical repair. METHODS: From 2015 to 2019, 3 patients underwent harvest of the femoral vein for use in SCA repair, with 2 carotid-axillary bypasses and 1 carotid-subclavian bypass. Indications included a mycotic pseudoaneurysm secondary to an infected SCA stent, an SCA avulsion secondary to an infected carotid-subclavian bypass graft, and an occluded SCA stent in a young patient. Postoperative graft patency was monitored via clinical resolution of symptoms and maintenance of perfusion, intact pulses, and arterial duplex or computed tomography (CT) scan. RESULTS: All these patients had a good outcome following their procedures. Each had intact radial pulses immediately postoperatively and maintained normal perfusion to the upper extremity for the duration of follow-up, with bypass patency confirmed via CT scan or arterial duplex. The SCA repair also allowed for salvage of the upper extremity and symptomatic relief in all patients. None of the patients developed deep vein thrombosis in the donor extremity, and neither of the infected patients developed recurrent infection of the repair site. CONCLUSIONS: The success of these cases demonstrates that the autogenous femoral vein is an effective and safe option for SCA reconstruction. It is particularly useful for secondary salvage when prior surgical repair via standard techniques is complicated by infection or thrombosis, and when target vessel size precludes the use of the great saphenous vein. This is an excellent choice of conduit that vascular surgeons should consider for use in complex SCA repairs.

Type B Aortic Dissection Complicated by Intimo-Intimal Intussusception and Extensive Intimal Denuding: Case Report with Long-term Follow-up.

BACKGROUND: Acute aortic dissection rarely results in circumferential dissections of the aortic intima that may lead to intimo-intimal intussusception (IIS) with complete separation from the aortic wall. Circumferential dissection may then result in distal embolization of the involved intima and media, adding considerable complexity to the management of such cases. Despite the severity of this complication, the natural history of aortic disease following extensive intimal denuding and IIS is not well documented in the literature. Here we present a case with long-term follow-up of type B aortic dissection (TBAD) complicated by IIS and embolization of the intima into the distal aorta following thoracic endovascular aortic repair. METHODS: Medical records and imaging studies were retrospectively reviewed with the approval of the Institutional Review Board. A single patient underwent repair of a TBAD that was complicated by IIS, with follow-up for 6 years. Aortic recovery was monitored with serial computerized tomography scans. RESULTS: During endovascular stent deployment, the patient's dissection progressed circumferentially, leading to distal embolization of the intima and aortic occlusion. An open transabdominal aortic exploration was performed to extract the embolized intima. Despite this severe aortic structural disruption, the patient recovered well postoperatively and exhibited favorable aortic remodeling over long-term follow-up. The denuded aorta did not rupture or develop progressive worsening aneurysmal dilation and the diameter of the involved aortic segment remained stable during follow-up. CONCLUSIONS: Acute TBADs can progress to circumferential intimal separation and IIS when managed with endovascular stenting and balloon dilation. Continued endovascular management once IIS has occurred may lead to further intimal damage, resulting in distal embolization of the intima and aortic occlusion. Thus, IIS may require conversion to open repair. However, in the event that loss of the aortic intima does occur following IIS, it is possible for the denuded aorta to recover well and remain stable with favorable remodeling over long-term follow-up.

The myristoylated alanine-rich C kinase substrate differentially regulates kinase interacting with stathmin in vascular smooth muscle and endothelial cells and potentiates intimal hyperplasia formation.

OBJECTIVE: Restenosis limits the durability of all cardiovascular reconstructions. Vascular smooth muscle cell (VSMC) proliferation drives this process, but an intact, functional endothelium is necessary for vessel patency. Current strategies to prevent restenosis employ antiproliferative agents that affect both VSMCs and endothelial cells (ECs). Knockdown of the myristoylated alanine-rich C kinase substrate (MARCKS) arrests VSMC proliferation and paradoxically potentiates EC proliferation. MARCKS knockdown decreases expression of the kinase interacting with stathmin (KIS), increasing p27kip1 expression, arresting VSMC proliferation. Here, we seek to determine how MARCKS influences KIS protein expression in these two cell types. METHODS: Primary human coronary artery VSMCs and ECs were used for in vitro experiments. MARCKS was depleted by transfection with small interfering RNA. Messenger RNA was quantitated with the real-time reverse transcription polymerase chain reaction. Protein expression was determined by Western blot analysis. Ubiquitination was determined with immunoprecipitation. MARCKS and KIS binding was assessed with co-immunoprecipitation. Intimal hyperplasia was induced in CL57/B6 mice with a femoral artery wire injury. MARCKS was knocked down in vivo by application of 10 µM of small interfering RNA targeting MARCKS suspended in 30% Pluronic F-127 gel. Intimal hyperplasia formation was assessed by measurement of the intimal thickness on cross sections of the injured artery. Re-endothelialization was determined by quantitating the binding of Evans blue dye to the injured artery. RESULTS: MARCKS knockdown did not affect KIS messenger RNA expression in either cell type. In the presence of cycloheximide, MARCKS knockdown in VSMCs decreased KIS protein stability but had no effect in ECs. The effect of MARCKS knockdown on KIS stability was abrogated by the 26s proteasome inhibitor MG-132. MARCKS binds to KIS in VSMCs but not in ECs. MARCKS knockdown significantly increased the level of ubiquitinated KIS in VSMCs but not in ECs. MARCKS knockdown in vivo resulted in decreased KIS expression. Furthermore, MARCKS knockdown in vivo resulted in decreased 5-ethynyl-2'-deoxyuridine integration and significantly reduced intimal thickening. MARCKS knockdown enhanced endothelial barrier function recovery 4 days after injury. CONCLUSIONS: MARCKS differentially regulates the KIS protein stability in VSMCs and ECs. The difference in stability is due to differential ubiquitination of KIS in these two cell types. The differential interaction of MARCKS and KIS provides a possible explanation for the observed difference in ubiquitination. The effect of MARCKS knockdown on KIS expression persists in vivo, potentiates recovery of the endothelium, and abrogates intimal hyperplasia formation.

Considerations beyond Stenosis for Carotid Endarterectomy in Treating Free-Floating Thrombus of the Carotid Artery.

BACKGROUND: Free-floating thrombus (FFT) of the carotid artery is an uncommon condition that can present with neurologic symptoms, often in the setting of ischemic stroke. The literature pertaining to the incidence and optimal treatment of this condition is limited. Herein, we report our contemporary experience with FFT across a range of degrees of carotid stenosis. METHODS: Medical records and imaging studies from a single academic medical center from January 2016 to July 2018 were retrospectively reviewed. Patient demographics, presentation, treatment, and follow-up were abstracted. RESULTS: Six cases of FFT of the carotid artery with and without hemodynamically significant atherosclerotic disease were identified. All cases presented with ischemic stroke; one case had a hemorrhagic conversion. In each case, the FFT was visualized by at least one imaging modality including computed tomography angiography, magnetic resonance angiography, and duplex ultrasound. Three patients had >50% carotid stenosis and three had <50%. All cases were treated with endarterectomy. Four of the six patients received preoperative anticoagulation. There were no postoperative complications. Median follow-up was 252 days, with one case lost to follow-up. Four of the six patients have been without restenosis, recurrence of the thrombus, nor worsening or recurrent stroke on follow-up. The fifth patient developed restenosis but remained clinically stable. CONCLUSIONS: Although current society guidelines do not recommend carotid endarterectomy as first-line treatment for symptomatic patients with <50% stenosis, it may be indicated in the context of FFT.

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) Not Yet Applicable for Widespread Out-of-Hospital Use: A Case of Nonsurvivable Complication from Prolonged REBOA Inflation.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is being considered for temporizing catastrophic hemorrhage before arriving at a specialty center for definitive surgical management. CASE: We describe the clinical case of a 72-year-old male with a ruptured infrarenal aortic abdominal aneurysm initially stabilized with REBOA at an outside facility and transferred to our care. Transport time was >100 minutes. Despite successful surgical repair of the ruptured aneurysm, the patient expired from multiple-organ failure likely related to ischemia-reperfusion injuries from prolonged balloon occlusion of the aorta. CONCLUSIONS: Ischemia-mitigating techniques and therapies need to improve drastically before the clinical application of REBOA can be effectively extended to outside the vicinity of specialty centers.

Continuous Flow Perfused Cadaver Model for Endovascular Training, Research, and Development.

BACKGROUND: Endovascular simulation employing computer, animal, and static models are common and useful adjuncts for teaching endovascular procedures and developing novel, complex endovascular techniques. Unfortunately, these models lack realistic haptic feedback and thus do not faithfully replicate many of the technical challenges associated with clinical endovascular procedures (e.g., arterial calcification, rigidity, and stenosis). We sought to develop a realistic and reproducible perfused cadaver model for endovascular training, device development, and research. METHODS: Fresh frozen, elderly (age 50-80 years) male cadavers were thawed and prepared for open dissection. The entire arterial tree (ascending aorta to femoral arteries) was dissected free and major branch vessels exposed. Sheaths were placed to allow outflow from selected vessels. A Dacron conduit was sewn to the ascending aorta to generate arterial inflow, which was provided by a centrifugal pump. Aortic aneurysms were created in the descending thoracic and abdominal aorta. Digital subtraction arteriography and various endovascular interventions were performed, including stent grafts and EndoAnchors deployment. RESULTS: Continuous antegrade flow was achieved in the thoracic, abdominal, iliac, and femoral segments. Open and percutaneous access at the femoral region was obtained with realistic back-bleeding and tactile feedback. Adequate, fluoroscopically documented flow was observed in both cannulated major and noncannulated smaller branches. We performed angiography with standard techniques via a pigtail catheter and contrast injector throughout the arterial system. Abdominal and thoracic endografts were deployed with appropriate angiographic guidance and realistic haptic feedback for both guidewire and stent grafts. Additional applications, including selective cannulation, aorto-iliac occlusive disease interventions, and anchor placement, were also successfully simulated. Finally, the model was used as a platform to test investigational devices. CONCLUSIONS: Our pressurized cadaver flow model successfully replicated multiple aspects of advanced endovascular procedures with haptic feedback. This novel human cadaver model allows for training and device development under clinically realistic conditions.

Transcervical Carotid Artery Stenting Using a Prosthetic Arterial Conduit: Case Series of a Novel Surgical Technique.

We present a series of 4 patients with carotid restenosis following carotid endarterectomy (CEA) who underwent transcervical carotid artery stenting (CAS) using a novel prosthetic conduit technique. The patients were high risk for repeat CEA (short and obese necks) and had contraindications to transfemoral CAS (bovine arch, prior dissection). CAS was thus performed via a transcervical approach with a polytetrafluoroethylene conduit anastomosed to the proximal common carotid artery. The addition of a conduit allowed stent placement via a secure, stable platform. All patients recovered from their procedure without incident and are free from restenosis at follow-up.

Flow Reduction-Aided Thrombin Injection for Complex Femoral Pseudoaneurysms: Case Series and Review of the Literature.

BACKGROUND: Peripheral pseudoaneurysms are a known complication of vascular access procedures. Complex lesions-those with short, wide necks or other complex arrangements-would conventionally require open repair, but we believe that even these lesions could be managed with an endovascular approach. METHODS: Four patients with complex pseudoaneurysms were offered an open repair or thrombin injection with the use of flow-reducing balloons. RESULTS: In our series of 4 patients with complex pseudoaneurysms, all were safely treated with percutaneous thrombin injection in conjunction with endovascular flow reduction. All patients recovered from their procedures without incident and are free from recurrence at follow-up. CONCLUSIONS: Flow reduction-aided thrombin injection may have particular utility in complex femoral pseudoaneurysms, especially in a patient population that may not tolerate open repair. High-risk lesions may merit special consideration for this technique, and further study is warranted.

Contemporary Single-Center Experience With Prophylactic Cerebrospinal Fluid Drainage for Thoracic Endovascular Aortic Repair in Patients at High Risk for Ischemic Spinal Cord Injury.

OBJECTIVE: To review rates of permanent paraplegia and lumbar drain-related complications in patients undergoing thoracic endovascular aortic repair (TEVAR) surgery with prophylactic cerebrospinal fluid (CSF) drainage at the authors' institution. DESIGN: Retrospective cohort study. SETTING: Tertiary care, academic medical center. PARTICIPANTS: Patients who underwent TEVAR with a high risk for ischemic spinal cord injury and prophylactic lumbar CSF drainage over a 5-year period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: One hundred and two patients underwent TEVAR with lumbar CSF drainage. Thirty-day mortality was 5.9%, and the rate of permanent paraplegia was 2%. Drain complications occurred in 4 (3.9%) patients, but no patient experienced permanent injury related to CSF drainage. Two patients in the cohort had complete resolution of paraplegia with increased CSF drainage and mean arterial blood pressure increases aimed to increase spinal cord perfusion pressure by 25%. A third patient experienced improvement in lower extremity strength but remained paraplegic, and a fourth patient demonstrated no improvement in symptoms. The 6 patients taking clopidogrel experienced no bleeding complications, and there were no apparent risk factors for bleeding in the 5 patients who had bloody drain output or in 1 patient who developed an epidural hematoma. CONCLUSION: Prophylactic CSF drainage was associated with low paraplegia and drain-related complication rates. These data further support the safety of prophylactic CSF drainage in patients undergoing TEVAR with a high risk for ischemic spinal cord injury.

Implications of concomitant hypogastric artery embolization with endovascular repair of infrarenal abdominal aortic aneurysms.

OBJECTIVE: Hypogastric artery embolization (HAE) is associated with significant risk of ischemic complications. We assessed the impact of HAE on 30-day outcomes of endovascular aneurysm repair (EVAR) of infrarenal abdominal aortic aneurysms. METHODS: We queried the American College of Surgeons National Surgical Quality Improvement Program database from 2011 to 2014 to identify and to compare clinical features, operative details, and 30-day outcomes of EVAR with those of concomitant HAE with EVAR (HAE + EVAR). Multivariate analysis was performed to determine preoperative and intraoperative factors associated with development of significant complications observed in patients with HAE + EVAR. RESULTS: In a cohort of 5881 patients, 387 (6.6%) underwent HAE + EVAR. Compared with EVAR, a higher incidence of ischemic colitis (2.6% vs 0.9%; P = .002), renal failure requiring dialysis (2.8% vs 1%; P = .001), pneumonia (2.6% vs 1.3%; P = .039), and perioperative blood transfusion (17% vs 13%; P = .024) was noted after HAE + EVAR. Thirty-day thromboembolic events, strokes, myocardial infarction, lower extremity ischemia, reoperation, and readmission rates were not significantly different (P > .05). Mortality at 30 days in HAE + EVAR patients was 4.1% compared with 2.5% with EVAR (P = .044). HAE was independently associated with increased risk of colonic ischemia (adjusted odds ratio, 2.98; 95% confidence interval, 1.44-6.14; P = .003) and renal failure requiring dialysis (adjusted odds ratio, 2.22; 95% confidence interval, 1.09-4.53; P = .029). However, HAE was not an independent predictor of mortality. Average length of hospital stay was 4 ± 8.5 days after HAE + EVAR vs 3.3 ± 5.9 days after EVAR (P = .001). CONCLUSIONS: Concomitant HAE with EVAR is associated with longer and more complicated hospital stays. Ischemic colitis is a rare complication of EVAR. HAE increases the risk of ischemic colitis and renal failure requiring dialysis. This study highlights the importance of hypogastric artery preservation during EVAR.

Management and outcomes of carotid artery extension of aortic dissections.

BACKGROUND: Aortic dissection (AD) is the most common aortic catastrophe. Carotid artery dissection due to extension of AD (CAEAD) is one severe complication of this condition. Despite years of refinement in the techniques for repair of AD, the optimal management strategy for CAEAD remains yet to be described. We hypothesized that CAEAD eventually resolves on antiplatelet therapy with a low but not insignificant risk of cerebrovascular accident (CVA). METHODS: This was a single-institution retrospective review of patients admitted with nontraumatic coincident aortic and carotid dissection between 2001 and 2013. RESULTS: CAEAD was present in 38 patients (24 men [53%]). The median age was 59.5 years (range, 25-85 years). A Stanford type A AD was diagnosed in 36 patients (95%). CVA or transient ischemic attack was identified in 11 patients (29%). Eight were potentially attributable to the carotid lesion. Two of these eight strokes resulted in death. Of the 11 CVAs and transient ischemic attacks, 8 were evident at presentation, 2 were diagnosed postoperatively during hospitalization, and 1 was diagnosed during early follow-up. Only one of these three postadmission strokes was attributable to the carotid lesion. Nonoperative management of aortic and carotid dissections was pursued in 9 patients (24%), 26 (68%) underwent open repair, and 4 (11%) had endovascular management of AD (2 thoracic endovascular aortic repair, 2 endovascular fenestrations), including 1 patient with a staged hybrid procedure (frozen elephant trunk). There were eight inpatient deaths (21%) and nine deaths in the follow-up period. Of the 30 patients who survived to discharge, 24 (80%) were managed with antiplatelet therapy. At a median follow-up of 14.5 months in 22 patients with follow-up computed tomography scans available, a minority of lesions had resolved, and only one CVA was reported. CONCLUSIONS: This study found that CAEAD was associated almost exclusively with type A AD, was typically unilateral, most often on the left, and usually persisted at follow-up. Many CAEAD patients presented with CVA and experienced significant early mortality. Notably, not all CVA events were attributable to the CAEAD. CVAs were not common after admission, and there appeared to be a low risk of new or subsequent stroke during follow-up with routine antiplatelet and antihypertensive therapy.

Functional status predicts major complications and death after endovascular repair of abdominal aortic aneurysms.

OBJECTIVE: Endovascular aneurysm repair (EVAR) is considered a lower risk option for treating abdominal aortic aneurysms and is of particular utility in patients with poor functional status who may be poor candidates for open repair. However, the specific contribution of preoperative functional status to EVAR outcomes remains poorly defined. We hypothesized that impaired functional status, based simply on the ability of patients to perform activities of daily living, is associated with worse outcomes after EVAR. METHODS: Patients undergoing nonemergent EVAR for abdominal aortic aneurysm between 2010 and 2014 were identified in the National Surgical Quality Improvement Program (NSQIP) database. The primary outcomes were 30-day mortality and major operative and systemic complications. Secondary outcomes were inpatient length of stay, need for reoperation, and discharge disposition. Using the NSQIP-defined preoperative functional status, patients were stratified as independent or dependent (either partial or totally dependent) and compared by univariate and multivariable analyses. RESULTS: Of 13,432 patients undergoing EVAR between 2010 and 2014, 13,043 were independent (97%) and 389 were dependent (3%) before surgery. Dependent patients were older and more frequently minorities; had higher rates of chronic pulmonary, heart, and kidney disease; and were more likely to have an American Society of Anesthesiologists score of 4 or 5. On multivariable analysis, preoperative dependent status was an independent risk factor for operative complications (odds ratio [OR], 3.1; 95% confidence interval [CI], 2.5-3.9), systemic complications (OR, 2.8; 95% CI, 2.0-3.9), and 30-day mortality (OR, 3.4; 95% CI, 2.1-5.6). Secondary outcomes were worse among dependent patients. CONCLUSIONS: Although EVAR is a minimally invasive procedure with substantially less physiologic stress than in open aortic repair, preoperative functional status is a critical determinant of adverse outcomes after EVAR in spite of the minimally invasive nature of the procedure. Functional status, as measured by performance of activities of daily living, can be used as a valuable marker of increased perioperative risk and may identify patients who may benefit from preoperative conditioning and specialized perioperative care.

Defining the burden, scope, and future of vascular acute care surgery.

OBJECTIVE: The paradigm of acute care surgery has revolutionized nonelective general surgery. Similarly, nonelective vascular surgery may benefit from specific management and resource capabilities. To establish the burden and scope of vascular acute care surgery, we analyzed the characteristics and outcomes of patients hospitalized for vascular surgical procedures in Maryland. METHODS: A retrospective analysis of a statewide inpatient database was performed to identify patients undergoing noncardiac vascular procedures in Maryland from 2009 to 2013. Patients were stratified by admission acuity as elective, urgent, or emergent, with the last two groups defined as acute. The primary outcome was inpatient mortality, and secondary outcomes were critical care and hospital resource requirements. Groups were compared by univariate analyses, with multivariable analysis of mortality based on acuity level and other potential risk factors for death. RESULTS: Of 3,157,499 adult hospital admissions, 154,004 (5%) patients underwent a vascular procedure; most were acute (54% emergent, 13% urgent), whereas 33% were elective. Acute patients had higher rates of critical care morbidity and required more hospital resource utilization. Admission for acute vascular surgery was independently associated with mortality (urgent odds ratio, 2.1; emergent odds ratio, 3.0). CONCLUSIONS: The majority of inpatient vascular care in Maryland is for acute vascular surgery, which is an independent risk factor for mortality. Acute vascular surgical care entails greater critical care and hospital resource utilization and-similar to emergency general surgery-may benefit from dedicated training and practice models.

Management and outcomes of blunt common and external iliac arterial injuries.

OBJECTIVE: Blunt iliac arterial injuries (BIAI) require complex management but are rare and poorly studied. We investigated the presentation, management, and outcomes of patients with blunt common or external iliac arterial injuries. METHODS: We identified and reviewed 112 patients with BIAI admitted between 2000 and 2011 at a Level I trauma center. Patients with common/external iliac artery injuries (CE group) were primarily analyzed, with patients with injuries of the internal iliac artery or its major branches (IB group) included for comparison of pelvic arterial trauma. RESULTS: Twenty-four patients had CE and 88 had IB injuries. Mean ages (45 ± 19 years) and gender (86% male) were similar between groups. The mean injury severity score was 40 ± 14 (CE, 36 ± 15; IB, 40 ± 14; P = .19), indicating severe trauma. Twenty (83%) of the CE patients presented with signs of leg malperfusion. Admission factors associated with CE injury were crush mechanism of injury (37% vs 17%; P = .03) and pelvic soft tissue trauma (50% vs 15%; P < .01). The CE group had higher early mortality rates, both within 3 hours of admission (50% vs 19%; P = .04) and prior to iliac intervention (42% vs 3%; P < .01). Among those surviving to management, CE patients were more likely to undergo open repair or revascularization (68% vs 3%; P < .01) and had a higher rate of leg amputation (50% vs 6%; P < .01), with 8/12 (67%) culminating in hemipelvectomy. Risk factors for amputation included leg malperfusion, high-grade pelvic fractures, pelvic soft tissue trauma, and increasing leg injury severity. Overall mortality was 40%, and was similar between the injury groups. Among CE patients, need for amputation, pelvic fractures, and wounds were associated with inpatient mortality. CONCLUSIONS: This is the largest series to date of blunt CE injuries and demonstrates distinct clinical features and outcomes for these patients. They have high risk for early death and proximal leg amputation. CE injury is specifically associated with serious open pelvic soft tissue injury, which, along with high-grade pelvic fractures, is a risk factor for amputation and death. On-demand emergent endovascular intervention may play an important role in improving management of these complex injuries.

Patterns and management of blunt abdominal aortic injury.

BACKGROUND: Blunt abdominal aortic injury (BAAI) is historically associated with significant morbidity and mortality. Our institutional experience was analyzed to define current patterns of injury and to help guide management. METHODS: Adult patients with BAAI between January 2000 and July 2011 were identified from our trauma registry. Medical, radiographic, and autopsy records were reviewed for relevant clinical data. Management and outcomes were compared between patients with minimal aortic injury limited to the intima (MAI) compared to more significant aortic injury (SAI). RESULTS: Nine patients had MAI and 8 had SAI, including 2 dissections, 2 pseudoaneurysms, 2 branch avulsions, 1 thrombosis, and 1 transection. The MAI and SAI groups had similar demographics and patterns of injury, and all patients had significant polytrauma, with a mean injury severity score of 42. More MAI than SAI patients were managed nonoperatively (100% vs. 38%; P=0.01). All observed patients underwent repeat imaging during the index admission, 85% within 72 hours, and no observed lesions led to malperfusion, death, or progression during the index admission. One MAI progressed to a pseudoaneurysm within 8 months. Five SAI patients underwent aortic-related repairs, including 2 endovascular stent grafts, 2 open primary repairs, and 1 axillobifemoral bypass. Overall, 15 (88%) patients underwent procedures for any injury-9 required laparotomy (53%) and 2 underwent thoracotomy. There were 6 (35%) deaths, 2 attributable to aortic injury-1 from hemorrhage and 1 from hyperkalemic cardiac arrest after prolonged ischemia from infrarenal aortic occlusion. Among patients who survived the initial resuscitation, SAI was associated with a significantly higher mortality rate compared to MAI (50% vs. 0%; P=0.03). CONCLUSIONS: Patients with MAI are at low risk of complications and may be considered for observation. Patients with SAI requiring intervention manifest clinically and/or radiographically at presentation. Those not associated with bleeding, malperfusion, or thromboembolism may be observed with interval imaging. For all observed patients, long-term surveillance is required to document complete resolution or stability, because even MAI can progress to a more complex lesion.

Emergency department medication history taking: current inefficiency and potential for a self-administered form.

BACKGROUND: Emergency Departments (EDs) struggle with obtaining accurate medication information from patients. OBJECTIVE: Our aim was to estimate the proportion of urban ED patients who are able to complete a self-administered medication form and record patient observations of the medication information process. METHODS: In this cross-sectional study, we consecutively sampled ED patients during various shifts between 8 AM and 10 PM. We created a one-page medication questionnaire that included a list of 49 common medications, categorized by general indications. We asked patients to circle any medications they took and write the names of those not on the form in a dedicated area on the bottom of the page. After their visit, we asked patients to recall which providers had asked them about their medications. RESULTS: Research staff approached 354 patients; median age was 45 years (interquartile range 29-53 years). Two hundred and forty-nine (70%) completed a form, 61 (17%) were too ill, 19 (5%) could not read it, and 25 (7%) refused to participate. Excluding refusals, 249 of 329 (76%; 95% confidence interval 70-80%) were able to complete the form. Of 209 patients recalling their visit, 180 (86%) indicated that multiple providers took a history, including 103 in which every provider did so, and 9 (4%) indicated that no provider took a medication history. CONCLUSIONS: The process of ED medication information transfer often involves redundant efforts by the health care team. More than 70% of patients presenting for Emergency care were able to complete a self-administered medication information form.

Predictive Factors for Mortality Following Major Lower Extremity Amputation.

BACKGROUND: Despite advances in techniques and care, major amputation bears a high risk for mortality. Previously identified factors associated with increased risk of mortality include amputation level, renal function, and pre-operative white cell count. METHODS: A single center retrospective chart review was conducted identifying patients who had undergone a major amputation. Chi-squared, t-testing, and Cox proportional hazard modeling were performed examining death at 6 months and 12 months. RESULTS: Factors associated with an increased risk of six-month mortality include age (OR 1.01-1.05, P < .001), sex (OR 1.08-3.24, P < .01), minority race (OR 1.18-18.19, P < .01), chronic kidney disease (OR 1.40-6.06, P < .001), and use of pressors at the induction of anesthesia for index amputation (OR 2.09-7.85, P < .000). Factors associated with increased risk of 12 month mortality were similar. DISCUSSION: Patients undergoing major amputation continue to suffer high mortality. Those patients who received their amputation under physiologically stressful conditions were more likely to die within 6 months. Reliably predicting six-month mortality can assist surgeons and patients in making appropriate care decisions.