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The American Surgeon Jul 2018The purpose of this study was to evaluate the impact of management of venous injury on clinical outcomes in patients with combined lower extremity arterial and venous... (Comparative Study)
Comparative Study
The purpose of this study was to evaluate the impact of management of venous injury on clinical outcomes in patients with combined lower extremity arterial and venous trauma. Patients with common and external iliac, common and superficial femoral, and popliteal artery injuries were identified. Patients who underwent vein repair and those who received vein ligation were compared. The analysis was repeated for those patients who required secondary intervention for their arterial injury and those who did not require secondary intervention. Seventy patients were identified with both arterial and venous injuries: 40 underwent vein ligation and 30 received vein repair. There was no difference in ischemic time between patients undergoing vein repair compared with ligation. Vein ligation did not produce a higher incidence of muscle debridement (10% vs 15%, P = 0.72), necessity for secondary intervention (10% vs 7.5%, P = 0.99), or amputation (3.3% vs 7.5%, P = 0.63). Patients who required secondary intervention had a greater degree of shock on presentation (packed red blood cells (PRBC), 13 units vs 6 units, P = 0.02) and were more likely to require muscle debridement (50% vs 9%, P = 0.02) and amputation (33% vs 3%, P = 0.03). Vein ligation did not impact muscle ischemia or success of arterial repair in patients with combined venous and arterial trauma in the lower extremities. Patient morbidity after extremity vascular trauma is most related to degree of shock.
Topics: Adolescent; Adult; Amputation, Surgical; Arteries; Debridement; Female; Humans; Leg Injuries; Ligation; Male; Reoperation; Retrospective Studies; Risk Factors; Treatment Outcome; Vascular Surgical Procedures; Vascular System Injuries; Veins
PubMed: 30064592
DOI: No ID Found -
Circulation. Arrhythmia and... Jun 2022Phrenic nerve palsy is a well-known complication of cardiac ablation, resulting from the application of direct thermal energy. Emerging pulsed field ablation (PFA) may...
BACKGROUND
Phrenic nerve palsy is a well-known complication of cardiac ablation, resulting from the application of direct thermal energy. Emerging pulsed field ablation (PFA) may reduce the risk of phrenic nerve injury but has not been well characterized.
METHODS
Accelerometers and continuous pacing were used during PFA deliveries in a porcine model. Acute dose response was established in a first experimental phase with ascending PFA intensity delivered to the phrenic nerve (n=12). In a second phase, nerves were targeted with a single ablation level to observe the effect of repetitive ablations on nerve function (n=4). A third chronic phase characterized assessed histopathology of nerves adjacent to ablated cardiac tissue (n=6).
RESULTS
Acutely, we observed a dose-dependent response in phrenic nerve function including reversible stunning (R=0.965, <0.001). Furthermore, acute results demonstrated that phrenic nerve function responded to varying levels of PFA and catheter proximity placements, resulting in either: no effect, effect, or stunning. In the chronic study phase, successful isolation of superior vena cava at a dose not predicted to cause phrenic nerve dysfunction was associated with normal phrenic nerve function and normal phrenic nerve histopathology at 4 weeks.
CONCLUSIONS
Proximity of the catheter to the phrenic nerve and the PFA dose level were critical for phrenic nerve response. Gross and histopathologic evaluation of phrenic nerves and diaphragms at a chronic time point yielded no injury. These results provide a basis for understanding the susceptibility and recovery of phrenic nerves in response to PFA and a need for appropriate caution in moving beyond animal models.
Topics: Animals; Atrial Fibrillation; Catheter Ablation; Peripheral Nerve Injuries; Phrenic Nerve; Pulmonary Veins; Swine; Vena Cava, Superior
PubMed: 35649121
DOI: 10.1161/CIRCEP.121.010127 -
Scientific Reports Mar 2019Rotational thromboelastometry is recommended to guide haemostatic therapy in trauma-related coagulopathy. In the case of unsuccessful venepuncture, intraosseous access... (Comparative Study)
Comparative Study Observational Study
Rotational thromboelastometry is recommended to guide haemostatic therapy in trauma-related coagulopathy. In the case of unsuccessful venepuncture, intraosseous access allows immediate administration of drugs and volume replacement. Feasibility of rotational thromboelastometry from intraosseous blood has not yet been investigated in humans. We performed rotational thromboelastometry and standard coagulation assays from intraosseous and intravenous blood samples in 19 volunteers and 4 patients undergoing general anaesthesia. Intraosseous access was performed either at the tibial bone or the proximal humerus. We observed visible clotting in the majority of the intraosseous samples. Only 13% of the probes allowed realization of rotational thromboelastometry. ROTEM parameters are reported as follows: shorter median clotting time (CT) in EXTEM, INTEM, and APTEM (53 vs. 68 s; 140 vs. 154 s; 54 vs. 62.5 s) and smaller median maximal clot firmness (MCF) in EXTEM and APTEM (56 vs. 63 mm; 55 vs. 62 mm) in intraosseous samples. We found no relevant differences in median MCF values in FIBTEM and INTEM (12 vs. 13 mm; 60 vs. 59 mm). Given the difficulties we faced during IO blood sampling in a study setting, we advise against ROTEM measurements out of IO blood for guidance of procoagulant therapy in emergency situations.
Topics: Adolescent; Adult; Blood Coagulation; Case-Control Studies; Feasibility Studies; Female; Humans; Humerus; Male; Middle Aged; Thrombelastography; Tibia; Veins; Wounds and Injuries; Young Adult
PubMed: 30842625
DOI: 10.1038/s41598-019-40412-0 -
Journal of the American College of... Feb 2023Injury to the inferior vena cava (IVC) can produce bleeding that is difficult to control. Endovascular balloon occlusion provides rapid vascular control without...
Injury to the inferior vena cava (IVC) can produce bleeding that is difficult to control. Endovascular balloon occlusion provides rapid vascular control without extensive dissection and may be useful in large venous injuries, especially in the juxtarenal IVC. We describe the procedural steps, technical considerations, and clinical scenarios for using the Bridge occlusion balloon (Philips) in IVC trauma. We present a single-center case series of 5 patients in which endovascular balloon occlusion of the IVC was used for hemorrhage control. All 5 patients were men (median age 35, range 22 to 42 years). They all sustained penetrating injuries-4 gunshot wounds and 1 stab wound. Median presenting Shock Index was 0.7 (range 0.5 to 1.5). Median initial lactate was 5.4 mmol/L (range 4.6 to 6.9 mmol/L). There were 2 suprarenal IVC injuries, 2 juxtarenal injuries, and 3 infrarenal injuries. Four patients underwent primary repair of their injury, and one underwent IVC ligation. Four patients had intraoperative Resuscitative Endovascular Balloon Occlusion of the Aorta for inflow control and afterload support. The median number of total blood products transfused during the initial operation was 37 units (range 16 to 77 units). Four patients underwent damage control operations, and one patient had a single definitive operation. Four of the 5 patients (80%) survived to discharge with the lone mortality being due to other injuries. Endovascular balloon occlusion serves as a valuable adjunct in the management of IVC injury and demonstrates the potential of hybrid open-endovascular operative techniques in abdominal vascular trauma.
Topics: Male; Humans; Young Adult; Adult; Female; Wounds, Gunshot; Vena Cava, Inferior; Wounds, Penetrating; Abdominal Injuries; Hemorrhage; Vascular System Injuries; Endovascular Procedures; Balloon Occlusion
PubMed: 36165502
DOI: 10.1097/XCS.0000000000000436 -
Journal of Pediatric Surgery Apr 2015Serum lactate measurement has a predictive value in adult trauma. To date, there has been no prospective analysis of the predictive value of admission serum lactate in... (Clinical Trial)
Clinical Trial
BACKGROUND/PURPOSE
Serum lactate measurement has a predictive value in adult trauma. To date, there has been no prospective analysis of the predictive value of admission serum lactate in pediatric trauma.
METHODS
Admission serum lactate was prospectively measured over a two year period on all children under age 15 years who met trauma alert criteria at an urban Level 1 trauma center. Elevated serum lactate (>2.0 mmol/L) was correlated with Injury Severity Scores (ISS), injury types, and hospital outcomes.
RESULTS
A total of 277 injured children with admission lactate measurements were evaluated. Patients with elevated lactate had higher mean ISS than those with normal lactate (12.8 vs. 5.1, p<0.01), and increased need for intubation, major procedures and ICU admission. Elevated lactate was associated with low specificity (54.4%), moderate sensitivity (86.7%) and high negative predictive value (94.5%) for detecting injury (ISS>15). Lactate measurements over 4.7 mmol/L were highly specific (95.8%) for injury.
CONCLUSIONS
Elevated admission venous lactate level is associated with injury and outcomes, but lacks adequate sensitivity and specificity. Lactate over 4.7 mmol/L is strongly suggestive of severe injury, while lactate below 2.0 mmol/L is reassuring for not having injury. Lactates between 2.0 and 4.7 mmol/L remain indeterminate in predictive potential for injury or outcomes.
Topics: Adolescent; Biomarkers; Child; Child, Preschool; Female; Hospitalization; Humans; Infant; Infant, Newborn; Injury Severity Score; Lactic Acid; Male; Predictive Value of Tests; Prognosis; Prospective Studies; Sensitivity and Specificity; Trauma Centers; Wounds and Injuries
PubMed: 25840070
DOI: 10.1016/j.jpedsurg.2014.08.013 -
Journal of Vascular Surgery. Venous and... May 2020Popliteal vascular injuries are common and frequently associated with limb loss. Although many studies have evaluated the treatment and outcomes of popliteal artery... (Comparative Study)
Comparative Study
BACKGROUND
Popliteal vascular injuries are common and frequently associated with limb loss. Although many studies have evaluated the treatment and outcomes of popliteal artery injuries (PAI), there is little available evidence regarding popliteal venous injuries (PVI). As such, substantial debate remains regarding the benefit of repair over ligation of PVI. The objectives of this study were to compare in-hospital outcomes of repair versus ligation of isolated PVI, as well as to determine nonvascular factors associated with worse outcomes.
METHODS
Patients in the National Trauma Databank from 2007 to 2014 with at least one PVI were evaluated. First, patients with concomitant PVI and PAI were compared with patients with isolated PVI. Second, outcomes were compared between ligation and repair of isolated PVI. To limit the impact of concomitant injuries and focus on the impact of venous injury management, we defined isolated PVI as cases without concomitant PAI and with Abbreviated Injury Scale severity score of less than 3 for all body regions other than lower extremity. Patients dead on arrival and those with less than 18 years of age were excluded. The primary outcomes were in-hospital mortality, amputation, and in-hospital amputation-free survival (AFS). Secondary outcomes included lower extremity compartment syndrome, fasciotomy, acute kidney injury, pulmonary embolism, deep venous thrombosis, and inferior vena cava filter placement.
RESULTS
Overall, 1819 patients (0.03%) had a PVI and after exclusion 1213 met the criteria for initial analysis. Of those, 308 had isolated PVI, and 905 had combined PVI and PAI. Patients with combined PVI and PAI had higher rates of amputation (15.2% vs 6.8%; P < .001), fasciotomy (64.5% vs 30.8%; P < .001), compartment syndrome (14.8% vs 8.8%; P = .006), and a lower AFS (82.9% vs 91.8%; P < .001) than patients with isolated PVI. There was no difference in in-hospital mortality, amputation, or in-hospital AFS between ligation and repair of isolated PVI. On multivariable logistic regression of isolated PVI, ligation was not independently associated with in-hospital AFS, amputation, or mortality.
CONCLUSIONS
Ligation of isolated PVI was not an independent predictor of in-hospital mortality, lower extremity amputation, or in-hospital AFS. Ligation also did not result in higher rates of fasciotomy, acute kidney injury, or pulmonary embolism.
Topics: Adult; Amputation, Surgical; Databases, Factual; Female; Hospital Mortality; Humans; Ligation; Limb Salvage; Male; Middle Aged; Popliteal Vein; Retrospective Studies; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome; United States; Vascular Surgical Procedures; Vascular System Injuries; Young Adult
PubMed: 31843477
DOI: 10.1016/j.jvsv.2019.09.014 -
Internal and Emergency Medicine Mar 2018The use of inferior vena cava filters to prevent pulmonary embolism is increasing mainly because of indications that appear to be unclearly codified and recommended. The... (Review)
Review
The use of inferior vena cava filters to prevent pulmonary embolism is increasing mainly because of indications that appear to be unclearly codified and recommended. The evidence supporting this approach is often heterogeneous, and mainly based on observational studies and consensus opinions, while the insertion of an IVC filter exposes patients to the risk of complications and increases health care costs. Thus, several proposed indications for an IVC filter placement remain controversial. We attempt to review the proof on the efficacy and safety of IVC filters in several "special" clinical settings, and assess the robustness of the available evidence for any specific indication to place an IVC filter.
Topics: Bariatric Surgery; Humans; Neoplasms; Neurosurgical Procedures; Pulmonary Embolism; Time Factors; Treatment Outcome; Vena Cava Filters; Vena Cava, Inferior; Venous Thrombosis; Wounds and Injuries
PubMed: 27873159
DOI: 10.1007/s11739-016-1575-7 -
Annals of Vascular Surgery Oct 2020The spiral saphenous vein graft is an excellent choice for venous reconstruction after periphery vein injury, but only few cases have been reported. We implanted a...
BACKGROUND
The spiral saphenous vein graft is an excellent choice for venous reconstruction after periphery vein injury, but only few cases have been reported. We implanted a segment of a single saphenous vein into both the popliteal vein as a venous vein graft and into the popliteal artery as an arterial vein graft at the same time in a trauma patient; we then had an extraordinary opportunity to harvest and examine both patent venous and arterial vein grafts at 2 weeks after implantation.
METHODS
A spiral saphenous vein graft was made as previously described and implanted into the popliteal vein and artery as interposition grafts; because of the patient's serious injuries, an amputation was performed at day 18 after vascular reconstruction. The grafts were harvested, fixed, and examined using histology and immunohistochemistry.
RESULTS
Both grafts were patent, and there was a larger neointimal area in the venous graft compared to the arterial graft. There were CD31- and vWF-positive cells on both neointimal endothelia, with subendothelial deposition of α-actin-, CD3-, CD45-, and CD68-positive cells. There were fewer cells in the venous graft neointima compared to the arterial graft neointima; however, there were more inflammatory cells in the neointima of the venous graft. Some of the neointimal cells were PCNA-positive, whereas very few cells were cleaved caspase-3 positive. The venous graft neointimal endothelial cells were Eph-B4 and COUP-TFII positive, while the arterial graft neointimal endothelial cells were dll-4 and Ephrin-B2 positive.
CONCLUSIONS
The spiral saphenous vein graft remains a reasonable choice for vessel reconstruction, especially in the presence of diameter mismatch. Both the venous and arterial grafts showed similar re-endothelialization and cellular deposition; the venous graft had more neointimal hyperplasia and inflammation. At an early time, endothelial cells showed venous identity in the venous graft, whereas endothelial cells showed arterial identity in the arterial graft.
CLINICAL RELEVANCE
Veins can be used as venous or arterial vein grafts but venous grafts have more neointimal hyperplasia and inflammation; vein grafts acquire different vessel identity depending on the environment into which they are implanted.
Topics: Amputation, Surgical; Biomarkers; Cell Plasticity; Cellular Microenvironment; Endothelial Cells; Humans; Injury Severity Score; Leg Injuries; Male; Middle Aged; Neointima; Popliteal Artery; Popliteal Vein; Saphenous Vein; Treatment Outcome; Vascular Grafting; Vascular Patency; Vascular Remodeling; Vascular System Injuries
PubMed: 32422286
DOI: 10.1016/j.avsg.2020.04.046 -
Annals of Vascular Surgery Feb 2018Major venous injury during open aortic reconstruction though uncommon often result in sudden and massive blood loss resulting in increased morbidity and mortality. This...
BACKGROUND
Major venous injury during open aortic reconstruction though uncommon often result in sudden and massive blood loss resulting in increased morbidity and mortality. This study details the etiology, management, and outcome of such injuries.
METHODS
A retrospective review of 945 patients (1981-2017) undergoing aortic reconstruction from 2 midsized (350 bed each) teaching hospitals was conducted. Seven hundred twenty-three patients (76.5%) underwent open abdominal aortic aneurysm (AAA) repair/iliac aneurysm repair, 222 patients (23.5%) underwent aortofemoral grafting (AFG). Patients sustaining major venous injury (sudden loss of more than 500 mL of blood) during major aortic reconstruction were studied. The number of units of packed red blood cells transfused, location of injured vessel, type of repair, postoperative morbidity, and mortality were collected in our vascular registry on a continuous basis. All patients identified with iliac vein/inferior vena cava/femoral vein injury had follow-up noninvasive venous examination of the lower extremities.
RESULTS
Eighteen major venous injuries (1.9%) occurred during aortic reconstruction in 17 patients (1 patient had 2 major venous injuries): IVC (n = 4), iliac vein (n = 10), left renal vein (n = 4, this includes a posterior retroaortic renal vein injury n = 1). Of the 18 major venous injuries, 7 occurred during open AAA repair for ruptured AAA and another 9 occurred during repair of intact AAA (P = 0.001), 2 venous injuries occurred after AFG, and 1 after primary AFG (P = 0.05). Using multivariate regression analysis, periarterial inflammation had significant association with major venous injury (P < 0.001). The presence of associated iliac aneurysm with abdominal aortic aneurysm also increased the incidence of major venous injury during AAA surgery (P = 0.05). Two patients (11.8%) died, one from uncontrolled bleeding due to tear of right common iliac vein during ruptured AAA repair and second patient from disseminated intravascular complication following repair of ruptured AAA. Intraoperative transfusion requirements were 3-28 units, (median 8 units). Three of 9 (33%) surviving patients developed iliofemoral venous thrombosis following repair of iliac/femoral vein injury.
CONCLUSIONS
Major venous injury during aortic reconstructions occurs more commonly during the repair of ruptured AAA and redo AFG. Following repair of iliac/femoral vein injury, surveillance for possible deep venous thrombosis by duplex imaging should be considered.
Topics: Aged; Aorta; Aortic Aneurysm, Abdominal; Aortic Rupture; Blood Loss, Surgical; Blood Transfusion; Chi-Square Distribution; Female; Hospital Bed Capacity; Hospitals, Teaching; Humans; Iatrogenic Disease; Iliac Vein; Logistic Models; Male; Michigan; Multivariate Analysis; Odds Ratio; Plastic Surgery Procedures; Registries; Renal Veins; Retrospective Studies; Risk Factors; Time Factors; Ultrasonography, Doppler, Duplex; Vascular Surgical Procedures; Vascular System Injuries; Veins; Vena Cava, Inferior; Venous Thrombosis
PubMed: 28887236
DOI: 10.1016/j.avsg.2017.08.004 -
Revista Latino-americana de Enfermagem 2018to determine the incidence rate and risk factors for the nursing-sensitive indicators phlebitis and infiltration in patients with peripheral venous catheters (PVCs).
OBJECTIVE
to determine the incidence rate and risk factors for the nursing-sensitive indicators phlebitis and infiltration in patients with peripheral venous catheters (PVCs).
METHOD
cohort study with 110 patients. Scales were used to assess and document phlebitis and infiltration. Socio-demographic variables, clinical variables related to the PVC, medication and hospitalization variables were collected. Descriptive and inferential analysis and multivariate logistic models were used.
RESULTS
the incidence rate of phlebitis and infiltration was respectively 43.2 and 59.7 per 1000 catheter-days. Most PVCs with these vascular traumas were removed in the first 24 hours. Risk factors for phlebitis were: length of hospital stay (p=0.042) and number of catheters inserted (p<0.001); risk factors for infiltration were: piperacillin/tazobactan (p=0.024) and the number of catheters inserted (p<0.001).
CONCLUSION
the investigation documented the incidence of nursing-sensitive indicators (phlebitis and infiltration) and revealed new risk factors related to infiltration. It also allowed a reflection on the nursing care necessary to prevent these vascular traumas and on the indications and contraindications of the PVC, supporting the implementation of the PICC as an alternative to PVC.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Catheterization, Peripheral; Cohort Studies; Extravasation of Diagnostic and Therapeutic Materials; Female; Humans; Incidence; Male; Middle Aged; Phlebitis; Risk Factors; Veins; Young Adult
PubMed: 29791668
DOI: 10.1590/1518-8345.2377.3002