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Echocardiography (Mount Kisco, N.Y.) Feb 2015Laboratory and field investigations have demonstrated that intrapulmonary arteriovenous anastomoses (IPAVA) may provide an additional means for venous gas emboli (VGE)... (Review)
Review
Laboratory and field investigations have demonstrated that intrapulmonary arteriovenous anastomoses (IPAVA) may provide an additional means for venous gas emboli (VGE) to cross over to the arterial circulation due to their larger diameter compared to pulmonary microcirculation. Once thought to be the primary cause of decompression sickness (DCS), it has been demonstrated that, even in large quantities, their presence does not always result in injury. Normally, VGE are trapped in the site of gas exchange in the lungs and eliminated via diffusion. When VGE crossover takes place in arterial circulation, they have the potential to cause more harm as they are redistributed to the brain, spinal column, and other sensitive tissues. The patent foramen ovale (PFO) was once thought to be the only risk factor for an increase in arterialization; however, IPAVAs represent another pathway for this crossover to occur. The opening of IPAVAs is associated with exercise and hypoxic gas mixtures, both of which divers may encounter. The goal of this review is to describe how IPAVAs may impact diving physiology, specifically during decompression, and what this means for the individual diver as well as the future of commercial and recreational diving. Future research must continue on the relationship between IPAVAs and the environmental and physiological circumstances that lead to their opening and closing, as well as how they may contribute to diving injuries such as DCS.
Topics: Arteriovenous Fistula; Decompression Sickness; Diving; Embolism, Air; Humans; Models, Cardiovascular; Pulmonary Artery; Pulmonary Veins
PubMed: 25693625
DOI: 10.1111/echo.12815 -
Vascular and Endovascular Surgery Jan 2020Although traumatic injuries to the superior mesenteric vein (SMV), portal vein (PV), and hepatic vein (HV) are rare, their impact is significant. Small single center... (Comparative Study)
Comparative Study
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 ( > .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%, < .001) and lower mortality (33.3% vs 45.9% vs 49.3%, < .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, = .05) in adult trauma patients; however, this was less than PV injury (OR = 2.77, CI = 1.56-4.93, = .001) and HV injury (OR = 2.70, CI = 1.46-4.99, = .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.
Topics: Adolescent; Adult; Child; Databases, Factual; Female; Hepatic Veins; Humans; Incidence; Male; Middle Aged; Portal Vein; Retrospective Studies; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome; United States; Vascular System Injuries; Young Adult
PubMed: 31570064
DOI: 10.1177/1538574419878577 -
Journal of Vascular Surgery. Venous and... Mar 2021Published outcomes on anterior lumbar interbody fusion (ALIF) have focused on 1-2 level fusion with and without vascular surgery assistance. We examined the influence of... (Comparative Study)
Comparative Study
BACKGROUND
Published outcomes on anterior lumbar interbody fusion (ALIF) have focused on 1-2 level fusion with and without vascular surgery assistance. We examined the influence of multilevel fusion on exposure-related outcomes when performed by vascular surgeons.
METHODS
We retrospectively reviewed clinical and radiographic data for patients undergoing anterior lumbar interbody fusion (ALIF) with exposure performed by vascular surgeons at a single practice.
RESULTS
From 2017-2018, 201 consecutive patients underwent vascular-assisted ALIF. Patients were divided by number of vertebral levels exposed (90 patients with 1 level exposed, 71 with 2, 40 with 3+). Demographically, 3+ level fusion patients were older (P=.0045) and more likely to have had prior ALIF (P=.0383). Increased vertebral exposure was associated with higher rates of venous injury (P=.0251), increased procedural time (P= .0116), length of stay (P=.0001), and incidence of postoperative DVT (P=.0032). There was a 6.5% rate of intraoperative vascular injury, comprised of 3 major and 10 minor venous injuries. In patients who experienced complications, 92.3% of injuries were repaired primarily. 23% of patients with venous injuries developed postoperative deep venous thrombosis. In a multivariate logistic regression model, increased levels of exposure (RR = 6.23, P = .026) and a history of degenerative spinal disease (RR = .033, P = .033) were predictive of intraoperative venous injury.
CONCLUSIONS
Increased vertebral exposure in anterior lumbar interbody fusion is associated with increased risk of intraoperative venous injury and postoperative deep venous thrombosis, with subsequently greater lengths of procedure time and length of stay. Rates of arterial and sympathetic injury were not affected by exposure extent.
Topics: Aged; Female; Humans; Length of Stay; Lumbar Vertebrae; Male; Middle Aged; Operative Time; Retrospective Studies; Risk Assessment; Risk Factors; Spinal Fusion; Time Factors; Treatment Outcome; Vascular System Injuries; Veins; Venous Thrombosis
PubMed: 32795618
DOI: 10.1016/j.jvsv.2020.08.006 -
CJEM Jul 2016Despite its relatively protected position, the liver is the most frequently injured solid intra-abdominal organ. 1 Most liver injuries can be managed conservatively, but... (Review)
Review
Despite its relatively protected position, the liver is the most frequently injured solid intra-abdominal organ. 1 Most liver injuries can be managed conservatively, but about 5% to 10% require urgent laparotomy, usually when the mechanism of injury involves a vehicle accident and hemodynamic instability persists, in spite of 40 mL/kg of blood transfusion. 2 , 3 In particular, grades IV and V liver injuries may pose a challenge to the surgeon trying to control hemorrhage, the leading cause of mortality. 4 Traumatic injuries to the portal vein are rare but devastating. The mortality rate for portal vein injury ranges from 50% to 70%. A recent study of portal triad injuries has highighted the higher mortality rates associated with combination injuries involving multiple portal triad components, especially those that include portal vein injury. 5 This case study describes a unique case of relatively minor trauma in a child resulting in portal triad injury, sudden demise, and surgical repair.
Topics: Abdominal Injuries; Bicycling; Bile Ducts, Extrahepatic; Blood Transfusion; Child; Emergency Service, Hospital; Follow-Up Studies; Glasgow Coma Scale; Humans; Injury Severity Score; Lacerations; Laparotomy; Liver; Male; Multiple Trauma; Portal Vein; Tomography, X-Ray Computed; Treatment Outcome; Ultrasonography, Doppler; Vascular Surgical Procedures
PubMed: 26087863
DOI: 10.1017/cem.2015.12 -
The Journal of Trauma and Acute Care... Jan 2021Following trauma, persistent inflammation, immunosuppression, and catabolism may characterize delayed recovery or failure to recover. Understanding the metabolic...
BACKGROUND
Following trauma, persistent inflammation, immunosuppression, and catabolism may characterize delayed recovery or failure to recover. Understanding the metabolic response associated with these adverse outcomes may facilitate earlier identification and intervention. We characterized the metabolic profiles of trauma victims who died or developed chronic critical illness (CCI) and hypothesized that differences would be evident within 1-week postinjury.
METHODS
Venous blood samples from trauma victims with shock who survived at least 7 days were analyzed using mass spectrometry. Subjects who died or developed CCI (intensive care unit length of stay of ≥14 days with persistent organ dysfunction) were compared with subjects who recovered rapidly (intensive care unit length of stay, ≤7 days) and uninjured controls. We used partial least squares discriminant analysis, t tests, linear mixed effects regression, and pathway enrichment analyses to make broad comparisons and identify differences in metabolite concentrations and pathways.
RESULTS
We identified 27 patients who died or developed CCI and 33 who recovered rapidly. Subjects were predominantly male (65%) with a median age of 53 years and Injury Severity Score of 36. Healthy controls (n = 48) had similar age and sex distributions. Overall, from the 163 metabolites detected in the samples, 56 metabolites and 21 pathways differed between injury outcome groups, and partial least squares discriminant analysis models distinguished injury outcome groups as early as 1-day postinjury. Differences were observed in tryptophan, phenylalanine, and tyrosine metabolism; metabolites associated with oxidative stress via methionine metabolism; inflammatory mediators including kynurenine, arachidonate, and glucuronic acid; and products of the gut microbiome including indole-3-propionate.
CONCLUSIONS
The metabolic profiles in subjects who ultimately die or develop CCI differ from those who have recovered. In particular, we have identified differences in markers of inflammation, oxidative stress, amino acid metabolism, and alterations in the gut microbiome. Targeted metabolomics has the potential to identify important metabolic changes postinjury to improve early diagnosis and targeted intervention.
LEVEL OF EVIDENCE
Prognostic/epidemiologic, level III.
Topics: Adult; Aged; Chronic Disease; Critical Illness; Female; Humans; Length of Stay; Male; Metabolomics; Middle Aged; Treatment Outcome; Wounds and Injuries
PubMed: 33017357
DOI: 10.1097/TA.0000000000002952 -
Surgery Apr 2018Trauma-induced coagulopathy is common and associated with poor outcome in injured children. Our aim is to identify patterns of coagulation dysregulation after injury and... (Clinical Trial)
Clinical Trial
BACKGROUND
Trauma-induced coagulopathy is common and associated with poor outcome in injured children. Our aim is to identify patterns of coagulation dysregulation after injury and associate these phenotypes with relevant clinical outcomes.
METHODS
We performed principal components analysis on prospectively collected data from children with the highest-level trauma activation June 2015-June 2016. Parameters included admission international normalized ratio, platelet count and thromboelastograms. Variables were reduced to principal components; principal component scores were generated for each subject and used in logistic regression with outcomes including mortality, disability, venous thromboembolism, and blood transfusion in the first 24 hours.
RESULTS
We included 133 subjects with median interquartile range age =10 (5-13 years), median interquartile range Injury Severity Score =17 (9-25), 73.5% boys, 70.8% blunt trauma. principal component analysis identified 3 significant principal components accounting for 75.0% of overall variance. Principal component 1 reflected clot strength; principal component 2 reflected abnormal fibrinolysis, both hyperfibrinolysis and fibrinolysis shutdown; principal component 3 reflected global clotting factor depletion. High principal component 1 score was associated with increased mortality (odds ratio =1.63) and blood transfusion (odds ratio 1.36). Principal component 2 score was correlated with Injury Severity Score (rho 0.4) and associated with venous thromboembolism (odds ratio 1.84), functional disability (odds ratio 1.66), mortality (odds ratio 2.07) and blood transfusion (odds ratio 2.79). PC3 score was associated with increased mortality (odds ratio 1.92) and blood transfusion (odds ratio 1.25).
CONCLUSION
Principal component analysis detects 3 patterns of coagulation dysregulation using widely available laboratory parameters: (1) abnormalities in clot strength; (2) abnormalities in fibrinolysis, and (3) clotting factor depletion. While all were associated with mortality and transfusion, fibrinolytic dysregulation was associated with injury severity and portends particularly poor outcome including venous thromboembolism and disability.
Topics: Adolescent; Blood Coagulation Disorders; Blood Transfusion; Child; Child, Preschool; Female; Humans; Injury Severity Score; International Normalized Ratio; Logistic Models; Male; Phenotype; Platelet Count; Principal Component Analysis; Prognosis; Prospective Studies; Thrombelastography; Wounds and Injuries
PubMed: 29248181
DOI: 10.1016/j.surg.2017.09.031 -
Annals of Vascular Surgery Aug 2021Inferior vena cava (IVC) injuries have a high mortality rate that may be related to the location of injury and type of repair. Previous studies have been either single... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
Inferior vena cava (IVC) injuries have a high mortality rate that may be related to the location of injury and type of repair. Previous studies have been either single center series or database studies lacking granular detail. These have reported conflicting results. We aimed to perform a systematic review and meta-analysis of published literature evaluating ligation versus repair.
METHODS
Studies published in English on MEDLINE or EMBASE from 1946 through October 2018 were examined to evaluate mortality among patients treated with ligation versus repair of IVC injuries. Studies were included if they provided mortality associated with ligation versus repair and reported IVC injury by level. Risk of bias was assessed regarding incomplete and selective outcome reporting with Newcastle-Ottawa score of 7 or higher to evaluate study quality. We used a random-effects model with restricted maximum likelihood estimation method in R using the Metafor package to evaluate outcomes.
RESULTS
Our systematic review identified 26 studies, of which 14 studies, including 855 patients, met our inclusion criteria for meta-analysis. IVC ligation was associated with higher mortality than IVC repair (OR: 3.12, P < 0.01, I = 49%). Ligation of infrarenal IVC injuries was not statistically associated with mortality (OR: 3.13, P = 0.09). Suprarenal injury location compared to infrarenal (OR 3.11, P < 0.01, I = 28%) and blunt mechanism compared to penetrating (OR: 1.91, P = 0.02, I = 0%) were also associated with higher mortality.
CONCLUSIONS
In this meta-analysis, ligation of IVC injuries was associated with increased mortality compared to repair, but not specifically for infrarenal IVC injuries. Suprarenal IVC injury, and blunt mechanism was associated with increased mortality compared to infrarenal IVC injury and penetrating mechanism, respectively. Data are limited regarding acute renal injury and venous thromboembolic events after IVC ligation and may warrant multicenter studies. Standardized reporting of IVC injury data has not been well established and is needed in order to enable comparison of outcomes across institutions. In particular, reporting of injury location, severity, and repair type should be standardized. A contemporary prospective, multicenter study is needed in order to definitively compare surgical technique.
Topics: Adult; Female; Humans; Ligation; Male; Risk Assessment; Risk Factors; Treatment Outcome; Vascular Surgical Procedures; Vascular System Injuries; Vena Cava, Inferior
PubMed: 33826960
DOI: 10.1016/j.avsg.2021.02.032 -
Clinical Anatomy (New York, N.Y.) Nov 2014The adrenal veins may present with a multitude of anatomical variants, which surgeons must be aware of when performing adrenalectomies. The adrenal veins originate... (Review)
Review
The adrenal veins may present with a multitude of anatomical variants, which surgeons must be aware of when performing adrenalectomies. The adrenal veins originate during the formation of the prerenal inferior vena cava (IVC) and are remnants of the caudal portion of the subcardinal veins, cranial to the subcardinal sinus in the embryo. The many communications between the posterior cardinal, supracardinal, and subcardinal veins of the primordial venous system provide an explanation for the variable anatomy. Most commonly, one central vein drains each adrenal gland. The long left adrenal vein joins the inferior phrenic vein and drains into the left renal vein, while the short right adrenal vein drains immediately into the IVC. Multiple variations exist bilaterally and may pose the risk of surgical complications. Due to the potential for collaterals and accessory adrenal vessels, great caution must be taken during an adrenalectomy. Adrenal venous sampling, the gold standard in diagnosing primary hyperaldosteronism, also requires the clinician to have a thorough knowledge of the adrenal vein anatomy to avoid iatrogenic injury. The adrenal vein acts as an important conduit in portosystemic shunts, thus the nature of the anatomy and hypercoagulable states pose the risk of thrombosis.
Topics: Adrenal Glands; Endovascular Procedures; Humans; Hyperaldosteronism; Iatrogenic Disease; Renal Veins; Veins; Vena Cava, Inferior
PubMed: 24737134
DOI: 10.1002/ca.22374 -
Annals of Vascular Surgery Jul 2020Popliteal artery injury (PAI) is a rare occurrence in pediatric patients with significant consequences. Delays in diagnosis lead to severe complications such as lifelong... (Comparative Study)
Comparative Study
BACKGROUND
Popliteal artery injury (PAI) is a rare occurrence in pediatric patients with significant consequences. Delays in diagnosis lead to severe complications such as lifelong disability and limb loss. We sought to identify outcomes and clinical predictors of PAI in the pediatric trauma population.
METHODS
The Pediatric Trauma Quality Improvement Program (2014-2016) was queried for patients ≤17 years old with PAI. Patient demographics and outcomes were characterized. A comparison of patients sustaining blunt versus penetrating PAI was performed. A multivariable logistic regression analysis was used to identify predictors of PAI.
RESULTS
From 119,132 patients, 58 (<0.1%) sustained a PAI with 74.1% from blunt trauma. Most of the patients were male (75.9%) with a median age of 15 and median Injury Severity Score of 9. A majority of the patients were treated with open repair (62.1%) in comparison to endovascular repair (10.3%) and nonoperative management (36.2%). The rates of open and endovascular repair and nonoperative management were similar between blunt and penetrating PAI patients (P = not significant). Concomitant injuries included popliteal vein injury (PVI) (12.1%), posterior tibial nerve injury (3.4%), peroneal nerve injury (3.4%), and closed fracture/dislocation of the femur (22.4%), patella (25.9%), and tibia/fibula (29.3%). Overall complications included compartment syndrome (8.6%), below-knee amputation (6.9%), and above-knee amputation (3.4%). The overall mortality was 3.4%. Patients with PAI secondary to penetrating trauma had a higher rate of concomitant PVI (26.7% vs. 7%, P = 0.04) and posterior tibial nerve injury (13.3% vs. 0%, P = 0.02) but a lower rate of closed fracture/dislocation of the patella (0% vs. 34.9%, P = 0.008) and tibia/fibula (0% vs. 39.5%, P = 0.004) compared to patients with PAI from blunt trauma. Predictors for PAI included PVI (odds ratio [OR] 296.57, confidence interval [CI] = 59.21-1,485.47, P < 0.001), closed patella fracture/dislocation (OR 50.0, CI = 24.22-103.23, P < 0.001), open femur fracture/dislocation (OR 9.05, CI = 3.56-22.99, P < 0.001), closed tibia/fibula fracture/dislocation (OR 7.44, CI = 3.81-14.55, P < 0.001), and open tibia/fibula fracture/dislocation (OR 4.57, CI = 1.80-11.59, P < 0.001). PVI had the highest association with PAI in penetrating trauma (OR 84.62, CI = 13.22-541.70, P < 0.001) while closed patella fracture/dislocation had the highest association in blunt trauma (OR 52.01, CI = 24.50-110.31, P < 0.001).
CONCLUSIONS
A higher index of suspicion should be present for PAI in pediatric trauma patients presenting with a closed patella fracture/dislocation after blunt trauma. PVI is most strongly associated with PAI in penetrating trauma. Prompt recognition of PAI is crucial as there is a greater than 10% amputation rate in the pediatric population.
Topics: Adolescent; Age Factors; Amputation, Surgical; Child; Databases, Factual; Endovascular Procedures; Female; Fracture Dislocation; Humans; Leg Injuries; Limb Salvage; Male; Popliteal Artery; Popliteal Vein; Postoperative Complications; Retrospective Studies; Risk Factors; Time Factors; Treatment Outcome; United States; Vascular Surgical Procedures; Vascular System Injuries; Wounds, Nonpenetrating; Wounds, Penetrating
PubMed: 31978483
DOI: 10.1016/j.avsg.2020.01.079 -
Clinical Anatomy (New York, N.Y.) Jan 2015Venous drainage of the spine and spinal cord is accomplished through a complex network of venous structures compartmentalized to intrinsic, extrinsic, and extradural... (Review)
Review
Venous drainage of the spine and spinal cord is accomplished through a complex network of venous structures compartmentalized to intrinsic, extrinsic, and extradural systems. As the literature on this topic is scarce, the following review was performed to summarize the available literature into a single coherent format. The medical literature on the spinal venous system was reviewed using online sources as well as historical documents that were not available online in regard to history, embryology, anatomy, and physiology with a particular emphasis on the pathology affecting this system. The spinal venous system is complex and variable. Proper understanding of all aspects is critical for the management of the pathology that results from its failure.
Topics: Arteriovenous Fistula; Arteriovenous Malformations; Hemodynamics; Humans; Infections; Magnetic Resonance Imaging; Radiography; Spinal Cord; Spinal Cord Injuries; Spinal Neoplasms; Spine; Veins
PubMed: 24677178
DOI: 10.1002/ca.22354