Long-term functional outcomes of upper extremity civilian vascular trauma.

OBJECTIVE: Civilian analyses of long-term outcomes of upper extremity vascular trauma (UEVT) are limited. Our goal was to evaluate the management of UEVT in the civilian trauma population and explore the long-term functional consequences. METHODS: A retrospective review and analysis was performed of patients with UEVT at an urban Level 1 trauma center (2001-2022). Management and long-term functional outcomes were analyzed. RESULTS: There were 150 patients with UEVT. Mean age was 34 years, and 85% were male. There were 42% Black and 27% White patients. Mechanism was penetrating in 79%, blunt in 20%, and multifactorial in 1%. Within penetrating trauma, mechanism was from firearms in 30% of cases. Of blunt injuries, 27% were secondary to falls, 13% motorcycle collisions, 13% motor vehicle collisions, and 3% crush injuries. Injuries were isolated arterial in 62%, isolated venous in 13%, and combined in 25% of cases. Isolated arterial injuries included brachial (34%), radial (27%), ulnar (27%), axillary (8%), and subclavian (4%). The majority of arterial injuries (92%) underwent open repair with autologous vein bypass (34%), followed by primary repair (32%), vein patch (6.6%), and prosthetic graft (3.3%). There were 23% that underwent fasciotomies, 68% of which were prophylactic. Two patients were managed with endovascular interventions; one underwent covered stent placement and the other embolization. Perioperative reintervention occurred in 12% of patients. Concomitant injuries included nerves (35%), bones (17%), and ligaments (16%). Intensive care unit admission was required in 45%, with mean intensive care unit length of stay 1.6 days. Mean hospital length of stay was 6.7 days. Major amputation and in-hospital mortality rates were 1.3% and 4.6% respectively. The majority (72%) had >6-month follow-up, with a median follow-up period of 197 days. Trauma readmissions occurred in 19%. Many patients experienced chronic pain (56%), as well as motor (54%) and sensory (61%) deficits. Additionally, 41% had difficulty with activities of daily living. Of previously employed patients (57%), 39% experienced a >6-month delay in returning to work. Most patients (82%) were discharged with opioids; of these, 16% were using opioids at 6 months. CONCLUSIONS: UEVT is associated with long-term functional impairments and opioid use. It is imperative to counsel patients prior to discharge and ensure appropriate follow-up and therapy.

Vinculin Identified as a Potential Biomarker in Hand-Arm Vibration Syndrome Based on iTRAQ and LC-MS/MS-Based Proteomic Analysis.

Local vibration can induce vascular injuries, one example is the hand-arm vibration syndrome (HAVS) caused by hand-transmitted vibration (HTV). Little is known about the molecular mechanism of HAVS-induced vascular injuries. Herein, the iTRAQ (isobaric tags for relative and absolute quantitation) followed by liquid chromatography-tandem mass spectrometry (LC-MS/MS) proteomics approach was applied to conduct the quantitative proteomic analysis of plasma from specimens with HTV exposure or HAVS diagnosis. Overall, 726 proteins were identified in iTRAQ. 37 proteins upregulated and 43 downregulated in HAVS. Moreover, 37 upregulated and 40 downregulated when comparing severe HAVS and mild HAVS. Among them, Vinculin (VCL) was found to be downregulated in the whole process of HAVS. The concentration of vinculin was further verified by ELISA, and the results suggested that the proteomics data was reliable. Bioinformative analyses were used, and those proteins mainly engaged in specific biological processes like binding, focal adhesion, and integrins. The potential of vinculin application in HAVS diagnosis was validated by the receiver operating characteristic curve.

Outcomes of vascular trauma associated with an evolution in the use of endovascular management.

OBJECTIVE: The availability of endovascular techniques has led to a paradigm shift in the management of vascular injury. Although previous reports showed trends towards the increased use of catheter-based techniques, there have been no contemporary studies of practice patterns and how these approaches differ by anatomic distributions of injury. The objective of this study is to provide a temporal assessment of the use of endovascular techniques in the management of torso, junctional (subclavian, axillary, iliac), and extremity injury and to evaluate any association with survival and length of stay. METHODS: The American Association for the Surgery of Trauma (AAST) Prospective Observational Vascular Injury Treatment registry (PROOVIT) is the only large multicenter database focusing specifically on the management of vascular trauma. Patients in the AAST PROOVIT registry from 2013 to 2019 with arterial injuries were queried, and radial/ulnar, and tibial artery injuries were excluded. The primary aim was to evaluate the frequency in use of endovascular techniques over time and by body region. A secondary analysis evaluated the trends for junctional injuries and compared the mortality between those treated with open vs endovascular repair. RESULTS: Of the 3249 patients included, 76% were male, and overall treatment type was 42% nonoperative, 44% open, and 14% endovascular. Endovascular treatment increased an average of 2% per year from 2013 to 2019 (range, 17%-35%; R2 = .61). The use of endovascular techniques for junctional injuries increased by 5% per year (range, 33%-63%; R2 = .89). Endovascular treatment was more common for thoracic, abdominal, and cerebrovascular injuries, and least likely in upper and lower extremity injuries. Injury severity score was higher for patients receiving endovascular repair in every vascular bed except lower extremity. Endovascular repair was associated with significantly lower mortality than open repair for thoracic (5% vs 46%; P < .001) and abdominal injuries (15% vs 38%; P < .001). For junctional injuries, endovascular repair was associated with a non-statistically significant lower mortality (19% vs 29%; P = .099), despite higher injury severity score (25 vs 21; P = .003) compared with open repair. CONCLUSIONS: The reported use of endovascular techniques within the PROOVIT registry increased more than 10% over a 6-year period. This increase was associated with improved survival, especially for patients with junctional vascular injuries. Practices and training programs should account for these changes by providing access to endovascular technologies and instruction in the catheter-based skill sets to optimize outcomes in the future.

Blunt traumatic aortic injury in the elderly population.

OBJECTIVE: Blunt thoracic aortic injury (BTAI) is a major cause of morbidity and mortality in trauma patients. Although outcomes for BTAI have been described in younger patient populations, elderly patients may present with different patterns of injury and have unique factors contributing to morbidity and mortality. This study aims to describe patterns of presentation and management in elderly patients presenting with BTAI using a nationwide database. METHODS: Patients aged 65 years and older with BTAI from 2007 through 2016 were identified from the American College of Surgeons Trauma Quality Improvement Program database. Baseline demographics, initial physiologic variables, and clinical outcomes were extracted from the database. Our primary outcome was in-hospital mortality. An adjusted Poisson generalized regression model was used to compare rates of mortality for thoracic endovascular aortic repair (TEVAR), open repair, and nonoperative management. RESULTS: During the study period, 1322 patients aged 65 years and over sustained BTAI and survived past triage. Mean age was 74.7 years, and 60% were male. There were low incidence rates of concomitant major head (9.4%), spine (3.1%), and abdominal (5.7%) injuries. Three hundred fifty (26.5%) underwent TEVAR, 58 (4.4%) open repair, and 914 (69.1%) were managed nonoperatively. Utilization of TEVAR increased from 13.1% to 32.7% from 2007 to 2015, with subsequent decline to 19.9% in 2016 in favor of nonoperative management. Age, gender, and mean Injury Severity Scores (ISS) did not significantly differ by management. In-hospital mortality for the entire cohort was 37.9%. In an adjusted Poisson generalized regression model using inverse probability of treatment weighting controlling for age, race, gender, ISS, and hypotension, TEVAR was associated with the lowest mortality rate (1.31 deaths/100 person-years; 95% confidence interval [CI], 1.17-1.46) compared with open repair (2.53; 95% CI, 2.32-2.75; P < .001) and nonoperative management (3.91; 95% CI, 3.60-4.25; P < .001). There was a higher incidence of acute kidney injury, acute respiratory distress syndrome, and surgical site infection in the TEVAR group. CONCLUSIONS: This study describes the management of and outcomes for BTAI in the elderly population. The majority of patients did not undergo operative repair, which was associated with a higher risk of in-hospital mortality. In an adjusted analysis, TEVAR was associated with the lowest mortality rate, compared with open repair and nonoperative management.

White matter abnormalities mediate the association between masticatory dysfunction and cognition among older adults.

BACKGROUND: Masticatory parameters, such as reduced number of teeth and posterior contacts, have been shown to be associated with reduced cognitive status. The underlying mechanisms that affect these associations, are however, not well understood. OBJECTIVES: The study aims to investigate the association between masticatory dysfunction and cognition and explore the mediating effect of brain structure. METHODS: In this cross-sectional study, 45 older adults with subjective masticatory dysfunction (mean age 72.3 ± 4.0 years) were included. Mini-Mental State Examination score <25, brain trauma, neurological disease, neurodegenerative disorders, depression or poor Swedish language skills were criteria for exclusion. Cognitive functions (executive function and episodic memory) and masticatory dysfunction defined by functional occluding status (FOS; the number of occluding units and number of remaining teeth) were analysed with partial correlation models. Structural magnetic resonance imaging was performed on 28 feasible participants. Multiple regression analyses were performed to evaluate the predictive value of brain structure and white matter hypointensities (WM-hypo) on cognitive functions. A mediation analysis was applied to assess significant predictor/s of the association between FOS and cognition. RESULTS: Both episodic memory and executive functions were positively correlated with FOS. WM-hypo predicted cognitive status (executive function, p ≤ .01). WM-hypo mediated 66.6% (p = 0.06) of the association between FOS and executive functions. CONCLUSION: Associations between FOS and cognitive functions are reported, where FOS, a potential modifiable risk factor, was related to both episodic memory and executive functions. The mediating effect of WM-hypo on the association between FOS and executive functions highlights the impact of the vascularisation of the brain on the link between mastication and cognition. The present study provides increased knowledge that bridges the gap between masticatory dysfunction and cognition.

The Needle and the Damage Done: A Retrospective Review of the Health Impact of Recreational Intravenous Drug Use and the Collateral Consequences for Vascular Surgery.

BACKGROUND: The UK has one of the highest rates of recreational drug use and consequent deaths in Europe. Scotland is the "Drug deaths capital of Europe." Intravenous drug use can result in limb- and life-threatening pathology. This study aimed to characterise limb-related admissions associated with intravenous drug use, outcomes and healthcare expenditure. METHODS: Retrospective data collection between December 2011 and August 2018. Patients were identified through discharge codes. Admission details were extracted from electronic records and a database compiled. Statistical analyses were performed using Statistical Package for the Social Science, P < 0.05 denoted significance. RESULTS: There were 558 admissions for 330 patients (1-9 admissions/patient), mean age 37 years (+/-7.6 SD) and 196 (59.2%; 319 admissions, 57.2%) were male. Three hundred forty-eight (62.4%) admissions were to surgical specialties, predominantly Vascular Surgery (247). Including onward referrals, Vascular ultimately managed 54.8% of admissions. Patients presented with multiple pathologies: 249 groin abscesses; 38 other abscesses; 74 pseudoaneurysms; 102 necrotising soft tissue infections (NSTI); 85 cellulitis; 138 deep venous thrombosis (DVTs); 28 infected DVTs and 70 other diagnoses. Two hundred and seventy-seven admissions (220 patients) required operations, with 361 procedures performed (1-7 operations/admission). There were 24 major limb amputations and 74 arterial ligations. Eleven amputations were due to NSTI and 13 followed ligation (17.6% of ligations). During follow-up 50 (15.2%) patients died, of which 6 (12%) had amputations (OR 3.2, 95% CI 1.04-9.61, P = 0.043). Cumulative cost of acute care was £4,783,241. CONCLUSIONS: Limb-related sequalae of intravenous drug use represents a substantial surgical workload, especially for Vascular. These are complex, high-risk patients with poor outcomes and high healthcare costs.

Technical approach, outcomes, and exposure-related complications in patients undergoing anterior lumbar interbody fusion.

OBJECTIVE: To describe our technique, evaluate access related complications and factors contributing to adverse outcomes in patients undergoing retroperitoneal anterior lumbar interbody fusion (ALIF). METHODS: We conducted a retrospective analysis of prospectively collected data on patients undergoing ALIF at our institution from January 2008 to December 2017. Access was performed by a vascular surgeon who remained present for the duration of the case. Data collected included patients' demographics, comorbidities, exposure related complications and ileus. Study end points included major adverse events and minor complications. Major adverse events included any vascular injuries requiring repair, bowel and ureter injuries, postoperative bleeding requiring reoperation, myocardial infarction, stroke, venous thromboembolism (pulmonary embolism/deep venous thrombosis), wound dehiscence, and death. Minor complications included postoperative paralytic ileus, urinary tract infections, and surgical site infections. The incidence of incisional hernia was also evaluated. RESULTS: During this period, 1178 patients (514 males and 664 females; mean age, 54.1 ± 13.8 years) underwent a total of 2352 levels ALIF at our institution (single level, 422 patients; 2 levels, 450; 3 levels, 205; 4 levels, 98; 5 levels, 6; 6 levels, 1; and 7 levels, 1). The median estimated blood loss was 25 mL (interquartile range, 25-50). There were 57 exposure-related complications (4.8%), including vascular injuries (venous, 13; arterial, 4) in 17 patients (1.4%), bowel injuries in three patients (serosa tear in two and arterial embolization with subsequent bowel ischemia in one). Eleven of the 13 venous injuries (84.6%) occurred while exposing the L4 to L5 lumbar level. Two of the four patients with arterial injuries developed acute limb ischemia requiring embolectomy. One embolized to the superior mesenteric artery and underwent bowel resection. Twenty patients (1.7%) developed venous thromboembolism, two of whom had sustained left iliac vein injury during exposure. Sixteen patients (1.4%) developed a retroperitoneal hematoma/seroma with nine requiring evacuation in the operating room. Thirty-six patients (3.1%) developed postoperative ileus, defined as an inability to tolerate diet on postoperative day 3. Four patients (0.4%) had a postoperative myocardial infarction, and two had a stroke and two (0.17%) died within the first 30 postoperative days. Thirty-one patients developed incisional complications, including surgical site infection in 24 and incisional hernia in 7. CONCLUSIONS: Our findings suggest that ALIF exposure can be performed safely with a relatively low overall complication rate. The majority of vascular injuries associated with this procedure are venous in nature, occurring predominantly while exposing the L4 to L5 level and can be safely addressed by an experienced vascular team.

A Nationwide Analysis of Popliteal Vascular Injuries and Outcomes by Hospital Teaching Status.

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

Variations in the position of the aorta and vertebral safe zones in supine, prone, and lateral decubitus for adolescent idiopathic scoliosis.

PURPOSE: Analyze the modifications in the "safe zones" of T4-L4 vertebral bodies relative to aorta according to patient positioning, as well as in the relationship between the aorta and the vertebrae. METHODS: Patients with adolescent idiopathic scoliosis who underwent surgical treatment during 2017 were included. Preoperative whole spine MRI in supine, prone, and LD positions was performed. The safe zone right (SZR) was defined as the angle formed between X-axis (0º) and a line connecting the origin and the edge of the aorta, and the safe zone left (SZL) was the angle between the edge of the aorta to 180º (X-axis). RESULTS: A total of 21 patients were studied, median age was 15.2 years, and 71.4% were female. The mean SZR lied from 0°-86.1º at T4 to 0°-76.9º at L4 in supine, from 0°-84.05º at T4 to 0º-78.5º at L4 in prone, and from 0° to 91.75º at T4 to 0°-80.4º at L4 in LD. While the mean SZL was located from 155.4º-180º at T4 to 107.9º-180º at L4 in supine, from 134°-180° at T4 to 103.9°-180° at L4 in prone, and from 143.8º-180º at T4 to 106º-180º at L4 in LD. Statistically significant differences were found almost at all levels when comparing supine versus prone and LD. CONCLUSIONS: Patient positioning during spinal surgery significantly modifies T4-L4 vertebral safe zones relative to aorta. These variations should be taken into account when analyzing an MRI performed in supine if the patient is undergoing surgery in a different position, to avoid vascular-related injuries.

Rating the incidence of iatrogenic vascular injuries in thoracic and lumbar spine surgery as regards the approach: A PRISMA-based literature review.

PURPOSE: To assess the rate, timing of diagnosis, and repairing strategies of vascular injuries in thoracic and lumbar spine surgery as their relationship to the approach. METHODS: PubMed, Medline, and Embase databases were utilized for a comprehensive literature search based on keywords and mesh terms to find articles reporting iatrogenic vascular injury during thoracic and lumbar spine surgery. English articles published in the last ten years were selected. The search was refined based on best match and relevance. RESULTS: Fifty-six articles were eligible, for a cumulative volume of 261 lesions. Vascular injuries occurred in 82% of instrumented procedures and in 59% during anterior approaches. The common iliac vein (CIV) was the most involved vessel, injured in 49% of anterior lumbar approaches. Common iliac artery, CIV, and aorta were affected in 40%, 28%, and 28% of posterior approaches, respectively. Segmental arteries were injured in 68% of lateral approaches. Direct vessel laceration occurred in 81% of cases and recognized intraoperatively in 39% of cases. CONCLUSIONS: Incidence of iatrogenic vascular injuries during thoracic and lumbar spine surgery is low but associated with an overall mortality rate up to 65%, of which less than 1% for anterior approaches and more than 50% for posterior ones. Anterior approaches for instrumented procedures are at risk of direct avulsion of CIV. Posterior instrumented fusions are at risk for injuries of iliac vessels and aorta. Lateral routes are frequently associated with lesions of segmental vessels. Suture repair and endovascular techniques are useful in the management of these severe complications.

Patient survival and limb salvage after shark attack with major vascular injury: A case report.

Shark attacks are rare unique pathological processes. Some of them represent devastating injuries with a high morbidity and significant mortality. Related published articles are limited. The increased human interaction within the environment of sharks is the cause of rising incidence of such attacks. This study reported a case of level 4 shark injuries (shark-induced trauma scale) in a 33-year-old male patient, who presented with an extensive injury of the right lower limb with the characteristic features of shark bite. At admission the patient was in a state of shock with profuse bleeding that was controlled by tourniquet. The patient was resuscitated according to the advanced trauma life support. Clinical examination showed hard signs of vascular injury with absent pedal pulse, associated neurological deficits and severance at the knee joint. Prompt vascular intervention after resuscitation was performed to manage the major vascular injuries, together with proper washout and debridement of all the necrotic tissues under strong antibiotic coverage to prevent infection. After that, the patient underwent sequenced plastic, orthopedic, and neurological interventions. Strict follow-up was conducted, which showed that the patient was saved and achieved a functioning limb. This study aims to highlight the management of level 4 shark injuries, which are considered serious and challenging with a high fatality rate and a great risk of amputation due to the associated major vascular injuries. Immediate well organized management plan is crucial. Prompt resuscitation and surgical intervention by a highly-skilled medical team are required to improve the chance of patient survival and limb salvage.

The influence of hyperglycemia on neutrophil extracellular trap formation and endothelial glycocalyx damage in a mouse model of type 2 diabetes.

OBJECTIVES: Hyperglycemia induces vascular dysfunction that is thought to be initiated by neutrophils. Neutrophil activation produces endothelial injury by pathways that include NETosis, a type of specific cell death. In this study, we investigated the effects of hyperglycemia on neutrophil activation, cell death, NETosis, and endothelial glycocalyx damage using a mouse diabetes model. METHODS: We used db/db mice as a type 2 diabetes model, and C57BL/6 mice were the controls. At 5, 8, and 12 weeks of age, the proportion of CD11b+ granulocytes/monocytes, neutrophil extracellular trap (NET)-forming granulocytes/monocytes, and damaged and nonviable granulocytes/monocytes was analyzed. In addition, serum levels of high mobility group box 1, histone H3, and glycocalyx components that included syndecan-1 and hyaluronan were measured. RESULTS: In diabetic mice, we observed an increased proportion of CD11b+ granulocytes/monocytes. The proportion of NET-forming granulocytes/monocytes increased from the early stages of the experiments. The proportions of damaged and nonviable granulocytes/monocytes increased over time. In the 12-week-old diabetic mice, serum histone H3 levels increased. Circulating levels of syndecan-1 and hyaluronan decreased over time and were lower in diabetic mice. CONCLUSION: Neutrophil activation and cell death induce endothelial glycocalyx damage, and NET formation also participates in the mechanisms of vascular injury in type 2 diabetes.

Dual-Energy CT: A Paradigm Shift in Acute Traumatic Abdomen.

Abdominal trauma, one of the leading causes of death under the age of 45, can be broadly classified into blunt and penetrating trauma, based on the mechanism of injury. Blunt abdominal trauma usually results from motor vehicle collisions, fall from heights, assaults, and sports and is more common than penetrating abdominal trauma, which is usually seen in firearm injuries and stab wounds. In both blunt and penetrating abdominal trauma, an optimized imaging approach is mandatory to exclude life-threatening injuries. Easy availability of the portable ultrasound in the emergency department and trauma bay makes it one of the most commonly used screening imaging modalities in the abdominal trauma, especially to exclude hemoperitoneum. Evaluation of the visceral and vascular injuries in a hemodynamically stable patient, however, warrants intravenous contrast-enhanced multidetector computed tomography scan. Dual-energy computed tomography with its postprocessing applications such as iodine selective imaging and virtual monoenergetic imaging can reliably depict the conspicuity of traumatic solid and hollow visceral and vascular injuries.

The impact of urgent computed tomography angiography for gunshot wounds in extremities with concomitant vascular injuries on diagnosis and postoperative outcomes.

BACKGROUND AND OBJECTIVES: Computed tomography angiography represents one of the most important investigation modalities in the diagnosis and follow-up of vascular diseases. We prospectively compare between patients who have had preoperative computed tomography (CT) angiography and others who had not, to analyze the influence of CT angiography on the diagnosis and postoperative outcomes in gunshot cases. METHODS: A Cohort study to compare between patients who underwent preoperative CT angiography and others who had not, to analyze the influence of CT angiography on the diagnosis and postoperative outcomes in patients who suffer from urgent vascular reconstruction due to gunshot wounds in extremities with concomitant vascular injuries, in the time period from 17 February 2011 to 31 December 2011 in Al-Jalaa Hospital, Benghazi, Libya. RESULTS: During the study period, 89 patients were included, of whom 88 (99%) were males and 1 (1%) was female; the mean age was 29.5 years. Patients were arranged into two groups. The first group of 38 patients (43%) were operated urgently without preoperative CT angiographic evaluation. The second group of 51 patients (57%) have had a preoperative CT angiographic evaluation. CONCLUSION: In the light of our study, we favor the immediate operative exploration of gunshot wounds in extremities with concomitant hard signs of vascular injuries without waiting for preoperative CT angiography, thereby minimizing the shock state and ischemic interval. CT angiography may be required for a more stable patient to avoid unnecessary surgical exploration.

[An injury of major vessels during laparoscopic procedure in urology. Surgical management by analyzing of clinical cases].

An injury of major vessels is a life - threating complication in laparoscopic urology. Review of the literature and analysis of own cases have been performed. The authors offer original surgical management with using hand-assistant technic. It has advantages of open and laparoscopic approach.

Time-course of vascular dysfunction of brachial artery after transradial access for coronary angiography.

BACKGROUND: Prior studies have demonstrated endothelial and smooth muscle brachial artery dysfunction after transradial cardiac catheterization for diagnostic coronary angiography. The duration of this vascular dysfunction is unknown. OBJECTIVE: To determine the time-course of endothelial and smooth muscle cell dysfunction in the upstream brachial artery after transradial cardiac catheterization. METHODS: We studied 22 consecutive patients with suspected coronary artery disease (age 64.4 ± 7.7 years) undergoing diagnostic transradial cardiac catheterization. Using high-resolution vascular ultrasound, we measured ipsilateral brachial artery diameter changes during reactive hyperemia (endothelium-dependent dilatation) and administration of sublingual nitroglycerin (endothelium-independent dilatation). The measurements were taken at baseline (before cardiac catheterization), 6 h, 24 h, 1 week, and 1 month postprocedure. The contralateral brachial artery served as a control. RESULTS: Ipsilateral brachial artery diameter during endothelium-dependent dilatation decreased significantly compared with the contralateral diameters at 6 h and 24 h after transradial cardiac catheterization (3.22 vs. 4.11 and 3.29 vs. 4.11, respectively, P < 0.001). The administration of nitroglycerin did not affect this difference. At 1 week and 1 month postprocedure there was no significant difference in diameter of the ipsilateral versus the contralateral brachial artery. As expected the contralateral brachial artery showed no significant changes in diameter. CONCLUSION: Our results showed that transradial cardiac catheterization causes transient vascular endothelial and smooth muscle dysfunction of the ipsilateral brachial artery, which resolves within 1 week postprocedure. These findings strongly suggest the absence of systemic vascular dysfunction after transradial catheterization both immediately postprocedure as well as 1 week postprocedure. © 2015 Wiley Periodicals, Inc.

Vascular Injuries to the Neck After Penetrating Trauma: Diagnostic Performance of 40- and 64-MDCT Angiography.

OBJECTIVE: The purposes of this study were to assess the diagnostic performance of 40- and 64-MDCT angiography with digital subtraction angiography as the reference standard in the detection of arterial injuries in patients at high risk after penetrating neck trauma and to perform a separate analysis of injuries to the external carotid artery. MATERIALS AND METHODS: In a retrospective evaluation of 53 sets of angiograms from 51 patients with penetrating neck injury, three reviewers unaware of the digital subtraction angiographic findings reviewed the CT angiographic (CTA) images to discern the presence or absence of arterial injuries. Sensitivity and specificity of CTA were calculated per injury, and a separate analysis of external carotid artery injuries was performed. RESULTS: Sensitivity of CTA for detecting arterial injuries ranged from 75.7% (95% CI, 62.3-86.9%) to 82.2% (95% CI, 69.5-92.1%). Specificity ranged from 96.4% (95% CI, 94.0-98.4%) to 98.4% (95% CI, 96.0-100%). CTA was highly sensitive for detection of the subgroup of injuries involving the large-caliber vessels that contribute to cerebral circulation. These sensitivities ranged from 92.8% (95% CI, 66-98.8%) to 100% (95% CI, 76.6-100%) for internal carotid artery injuries and from 88.9% (95% CI, 65.2-98.3%) to 94.4% (95% CI, 72.6-99.0%) for vertebral artery injuries. In contrast, sensitivity of CTA was limited for external carotid artery injuries, ranging from 63.4% (95% CI, 45.5-79.5%) to 70.0% (95% CI, 52.0-85.0%). CONCLUSION: CTA can be used for initial evaluation and may help guide management decisions if an external carotid artery injury is detected. Negative findings should not preclude close clinical follow-up, repeat CTA evaluation, or, in the presence of high suspicion of arterial injury due to clinical findings or wound trajectory, evaluation with digital subtraction angiography.

An unusual penetrating cervical wound involving a disc grinder: A case report.

INTRODUCTION: Penetrating neck injuries pose a unique challenge due to the limited space for controlling bleeding and performing repairs. This often leads to high mortality rates when major blood vessels are severed, and can also result in neurological damage. CASE PRESENTATION: We present a case of a penetrating injury to the internal jugular vein caused by a dislodged angle grinder disc, a rare mechanism of injury with potentially fatal consequences. The patient underwent emergency surgery to explore the wound and ligate the injured veins. After the operation, the patient fully recovered with no neurological deficits and did not require further treatment. DISCUSSION: Angle grinders are well-known for causing severe penetrating neck injuries due to their high-speed operation. Venous vascular wounds can be controlled with ligation and have a good prognosis. Nerve injuries are common. Protective measures should be taken in these patients. CONCLUSION: This case highlights the significant risk of injury associated with disc grinders, and the importance of seeking prompt specialized medical attention.

Indications for computed tomography angiography in limb trauma.

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

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

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