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Annals of Vascular Surgery Feb 2021The ability to salvage the mangled lower extremity is both technically challenging and time consuming. It requires the collaborative efforts among multiple surgical...
BACKGROUND
The ability to salvage the mangled lower extremity is both technically challenging and time consuming. It requires the collaborative efforts among multiple surgical specialties in addition to comprehensive post-traumatic wound follow-up. Our institution has integrated a dynamic effort among these specialists in the planning and facilitating a successful limb salvage program with creation of a mangled extremity algorithm. An integral part in this process is the vascular inflow to prepare coverage for large tissue defects lacking adequate recipient targets. Utilization of long saphenous arteriovenous (AV) loop has been cited with minimal data available using larger inflow vessels in the acute trauma setting. We performed a retrospective review and describe our early experience using our protocol with AV loop creation with free flap reconstruction to salvage traumatic leg injuries. Using the data, we sought to develop a mangled extremity protocol for trauma centers to guide mangled limb salvage.
METHODS
Since June 2016, 398 patients were admitted to our level II trauma facility with isolated traumatic wounds to the lower extremities. Thirty-one limbs were deemed mangled in which 21 received primary amputations due to multiple factors. Ten patients admitted from the trauma service with isolated mangled lower extremities injuries were identified for review. All 10 patients sustained severe crush injuries with large soft tissue defects and decreased perfusion for healing but deemed salvageable by multispecialty assessment. Mangled extremity severity scores were tabulated. Patients age ranged from 21-44 years, with 8 men and 2 women. Repeated debridements until successful sterilization of the wounds were accomplished. Ten long saphenous vein AV loops were anastomosed to the at or above knee popliteal vessels for free flap reconstruction. All patients were followed post-AV loop creation for vascular complications and wound assessments.
RESULTS
All 10 patients had sterilization of the wounds with repair of the fracture site before vascular reconstruction. Mean debridement to surgical site sterilization was 4.3 washouts (range 2-7). Successful AV loop creation with long saphenous vein was completed in 100% of patients without vascular complications nor steal events. Free flap tissue transfers directly connected to the loop were completed using 6 rectus abdominis, 3 latissimus dorsi, and 1 anterior thigh graft within 10 days of its creation. Patency rates of the AV loop was 100% with 10 successful flap transfers and 90% amputation free survival. One flap did not survive due to recurrent bacterial infection of the hardware. The 9 patients with successful procedures reached preoperative ambulatory status within 3 months after their final surgery. At 24 months follow-up, 90% amputation free survival is still maintained.
CONCLUSIONS
Although a small patient cohort, utilization of long saphenous vein AV loop is successful as a bridge to free flap transfer for isolated mangled lower extremities. Development and incorporation of our mangled extremity protocol to guide limb salvage has proven successful in our early experience. Long-term data need to be complied to assess patency of the free flap transfer and quality of life outcomes.
Topics: Adult; Amputation, Surgical; Arteriovenous Shunt, Surgical; Crush Injuries; Debridement; Female; Femoral Artery; Free Tissue Flaps; Humans; Limb Salvage; Lower Extremity; Male; Middle Aged; Popliteal Artery; Popliteal Vein; Regional Blood Flow; Retrospective Studies; Saphenous Vein; Skin Transplantation; Time Factors; Treatment Outcome; Vascular System Injuries; Young Adult
PubMed: 32800890
DOI: 10.1016/j.avsg.2020.07.056 -
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 -
All the bang without the bucks: Defining essential point-of-care testing for traumatic coagulopathy.The Journal of Trauma and Acute Care... Jul 2015Rapid assessment and treatment of coagulopathy reduces postinjury morbidity and mortality. Although thrombelastography (TEG) may be more accurate and efficient than... (Comparative Study)
Comparative Study
BACKGROUND
Rapid assessment and treatment of coagulopathy reduces postinjury morbidity and mortality. Although thrombelastography (TEG) may be more accurate and efficient than conventional coagulation tests, it requires significant financial and personnel investments. We hypothesized that point-of-care international normalized ratio (POC INR) may provide a rapid and accurate alternative to TEG.
METHODS
A retrospective review of sequential trauma patients who underwent both POC INR and rapid TEG (r-TEG) testing upon presentation to a Level I trauma center from July 2012 to December 2013 was performed. POC INR was compared with r-TEG values (R value, K time, α angle, maximum amplitude, percent clot lysis in 30 minutes) and transfusion requirements. Vital signs, admission laboratory values, and injury severity were analyzed. POC INR and venous blood gas testing was performed in the emergency department. All results and Pearson correlations noted were significant if p < 0.05.
RESULTS
We identified 628 trauma patients with concomitant r-TEG and POC INR testing. Median Injury Severity Score (ISS) was 13, 20% arrived in shock (base value < -5), 21% were transfused, and 11% died. POC INR correlated with all r-TEG values, with stronger correlations for patients in shock. POC INR and r-TEG had similar correlations with blood products transfused at 4 hours and 24 hours, but only POC INR predicted substantial bleeding and massive transfusion. POC INR also correlated strongly with standard INR testing. POC INR test duration was less than 1 minute, compared with at least 30 minutes for r-TEG. Total cohort charges for POC INR were estimated at $21,980 versus $396,896 for r-TEG.
CONCLUSION
POC INR testing is faster and cheaper than r-TEG. In addition, POC INR correlates not only with r-TEG values but also with acute blood product transfusions. POC INR provides a practical alternative for rapid coagulopathy assessment in the trauma patient at institutions that lack TEG capability.
LEVEL OF EVIDENCE
Diagnostic study, level III. Therapeutic/care management study, level IV.
Topics: Adult; Blood Coagulation Disorders; Female; Humans; Injury Severity Score; International Normalized Ratio; Logistic Models; Male; Middle Aged; Point-of-Care Systems; Retrospective Studies; Sensitivity and Specificity; Thrombelastography; Wounds and Injuries
PubMed: 26091324
DOI: 10.1097/TA.0000000000000691 -
The Journal of International Medical... Apr 2022Central venous catheterization is a necessary and common method of building the circulation pathways of patients with end-stage kidney disease. Venous rupture is a...
Central venous catheterization is a necessary and common method of building the circulation pathways of patients with end-stage kidney disease. Venous rupture is a severe and fatal complication of central venous catheterization. We herein present a case of slowly occurring venous rupture after reinsertion of a left internal jugular vein (IJV) catheter. A man in his early 70s was hospitalized with end-stage kidney disease. We inserted a hemodialysis catheter through the left IJV. A short section of the patient's catheter slipped out 1 month later. The original catheter was reinserted at its primary position without a guidewire. The patient reported chest pain and developed hypotension during dialysis the next day. He underwent femoral venous catheter insertion and heparin-free dialysis. The patient finally recovered and underwent regular hemodialysis using an arteriovenous fistula in the left forearm. This is the first reported case of venous laceration after repeated left IJV catheterization. Left IJV catheterization is associated with high rates of complications and should be closely monitored with the help of radiography during and after the operation. Central venous catheters should be carefully placed with clear knowledge of their direction and location to prevent serious complications.
Topics: Catheterization, Central Venous; Catheters, Indwelling; Female; Humans; Jugular Veins; Kidney Failure, Chronic; Lacerations; Male; Renal Dialysis; Vascular System Injuries
PubMed: 35466740
DOI: 10.1177/03000605221093305 -
Journal of Vascular Surgery Dec 2018Recent studies have demonstrated an increase in trauma mortality relative to mortality from cancer and heart diseases in the United States. Major vascular injuries such... (Comparative Study)
Comparative Study
OBJECTIVE
Recent studies have demonstrated an increase in trauma mortality relative to mortality from cancer and heart diseases in the United States. Major vascular injuries such as to the inferior vena cava (IVC) and aortic injuries remain responsible for a significant proportion of early trauma deaths in modern trauma care. The purpose of this study was to explore patterns in epidemiology and mortality after IVC and aortic injuries in the United States.
METHODS
A 13-year analysis of the National Trauma Databank (2002-2014) was performed to extract all patients who sustained IVC, abdominal aortic, or thoracic aortic injuries. Demographics, clinical data, and outcomes were extracted. Patients were analyzed according to injury mechanism.
RESULTS
A total of 25,428 patients were included in this analysis. Overall, the mean age was 39.8 ± 19.1 years, 70.3% were male, and 14.1% sustained a penetrating trauma. Although the incidence of all three injuries remained constant throughout the study period, for blunt trauma, mortality decreased over the study period (from 48.8% in 2002 to 28.7% in 2014; P < .001), in particular for thoracic aortic injuries (from 46.1% in 2002 to 23.7% in 2014; P < .001) and abdominal aortic injuries (from 58.3% in 2002 to 26.2% in 2014; P < .001). This decrease in mortality after blunt trauma was accompanied by an increase in endovascular procedures over the study period (from 1.0% in 2002 to 30.4% in 2014; P < .001), in particular for blunt thoracic aortic injuries (from 0.7% in 2002 to 41.4% in 2014; P < .001). When penetrating trauma patients were analyzed, overall there was an increase in mortality (from 43.8% in 2002 to 50.6% in 2014; P < .001), in particular after abdominal aortic injury (from 30.4% in 2002 to 66.0% in 2014; P < .001). Similar trends were observed for IVC injuries. No increase in endovascular use in penetrating trauma was identified (from 0.1% in 2002 to 3.4% in 2014; P < .001).
CONCLUSIONS
The present study demonstrates an overall decrease in mortality after blunt aortic injuries in the United States. This decrease was accompanied by an increase in the use of endovascular procedures. After penetrating trauma, however, despite contemporary advances in trauma care, mortality has increased over the study period, in particular after abdominal aortic injury. No increase in endovascular use in penetrating trauma was demonstrated.
Topics: Abdominal Injuries; Adolescent; Adult; Aged; Aged, 80 and over; Aorta, Abdominal; Aorta, Thoracic; Child; Child, Preschool; Endovascular Procedures; Female; Humans; Incidence; Infant; Male; Middle Aged; Registries; Retrospective Studies; Thoracic Injuries; Time Factors; United States; Vascular Surgical Procedures; Vascular System Injuries; Vena Cava, Inferior; Wounds, Nonpenetrating; Wounds, Penetrating; Young Adult
PubMed: 30473029
DOI: 10.1016/j.jvs.2018.04.033 -
Acta Biomaterialia Aug 2019Electrospinning is commonly used to generate polymeric scaffolds for tissue engineering. Using this approach, we developed a small-diameter tissue engineered vascular...
Differential outcomes of venous and arterial tissue engineered vascular grafts highlight the importance of coupling long-term implantation studies with computational modeling.
Electrospinning is commonly used to generate polymeric scaffolds for tissue engineering. Using this approach, we developed a small-diameter tissue engineered vascular graft (TEVG) composed of poly-ε-caprolactone-co-l-lactic acid (PCLA) fibers and longitudinally assessed its performance within both the venous and arterial circulations of immunodeficient (SCID/bg) mice. Based on in vitro analysis demonstrating complete loss of graft strength by 12 weeks, we evaluated neovessel formation in vivo over 6-, 12- and 24-week periods. Mid-term observations indicated physiologic graft function, characterized by 100% patency and luminal matching with adjoining native vessel in both the venous and arterial circulations. An active and robust remodeling process was characterized by a confluent endothelial cell monolayer, macrophage infiltrate, and extracellular matrix deposition and remodeling. Long-term follow-up of venous TEVGs at 24 weeks revealed viable neovessel formation beyond graft degradation when implanted in this high flow, low-pressure environment. Arterial TEVGs experienced catastrophic graft failure due to aneurysmal dilatation and rupture after 14 weeks. Scaffold parameters such as porosity, fiber diameter, and degradation rate informed a previously described computational model of vascular growth and remodeling, and simulations predicted the gross differential performance of the venous and arterial TEVGs over the 24-week time course. Taken together, these results highlight the requirement for in vivo implantation studies to extend past the critical time period of polymer degradation, the importance of differential neotissue deposition relative to the mechanical (pressure) environment, and further support the utility of predictive modeling in the design, use, and evaluation of TEVGs in vivo. STATEMENT OF SIGNIFICANCE: Herein, we apply a biodegradable electrospun vascular graft to the arterial and venous circulations of the mouse and follow recipients beyond the point of polymer degradation. While venous implants formed viable neovessels, arterial grafts experienced catastrophic rupture due to aneurysmal dilation. We then inform a previously developed computational model of tissue engineered vascular graft growth and remodeling with parameters specific to the electrospun scaffolds utilized in this study. Remarkably, model simulations predict the differential performance of the venous and arterial constructs over 24 weeks. We conclude that computational simulations should inform the rational selection of scaffold parameters to fabricate tissue engineered vascular grafts that must be followed in vivo over time courses extending beyond polymer degradation.
Topics: Absorbable Implants; Aneurysm; Animals; Arteries; Biocompatible Materials; Blood Vessel Prosthesis; Computer Simulation; Female; Mice; Mice, SCID; Microscopy, Electron, Scanning; Reproducibility of Results; Rupture; Tissue Engineering; Veins
PubMed: 31200116
DOI: 10.1016/j.actbio.2019.05.063 -
Journal of Ultrasound Sep 2016In this prospective study, we studied the role of ultrasonography (US) in the diagnosis and management of penile trauma.
PURPOSE
In this prospective study, we studied the role of ultrasonography (US) in the diagnosis and management of penile trauma.
METHODS
Between 2007 and 2014, 14 patients (mean age 39 years) with suspected penile fracture underwent US examinations. Almost all patients had a history of injury during sexual intercourse or manipulation of the penis. US examinations were performed in transversal and longitudinal planes starting at the level of the glans and moving down to the base of the penis. Color-Doppler was used to identify the vascular pattern or to see any abnormal vascularity.
RESULTS
The most common blunt injury to the penis that occurred in nine patients was penile fracture due to rupture of the corpus cavernosum. A tear occurred in only one of the corpora cavernosa. US showed an irregular hypoechoic or hyperechoic defect at the cavernosal rupture site. Four patients presented an injury to the subtunical venous plexus in the absence of complete tunical disruption. One patient had urethral rupture with inability to urinate and apparent urethrorrhagia. Ten patients underwent surgical operation, while four patients were observed and discharged after 2 days. Mean follow-up was 32 months (range 3-58). After 8 to 12 weeks, all of them were able to be sexually active as before. Angulations of penis persisted in one patient.
CONCLUSION
US may be the preferred imaging technique for evaluation of penile fracture before surgery. It is easy to perform, non-invasive, widely available, and inexpensive, although it requires an experienced team.
Topics: Adolescent; Adult; Aged; Coitus; Disease Management; Follow-Up Studies; Humans; Male; Middle Aged; Penis; Prospective Studies; Ultrasonography, Doppler, Color; Wounds, Nonpenetrating; Young Adult
PubMed: 27635160
DOI: 10.1007/s40477-016-0195-4 -
PloS One 2019Machine learning techniques have demonstrated superior discrimination compared to conventional statistical approaches in predicting trauma death. The objective of this...
OBJECTIVE
Machine learning techniques have demonstrated superior discrimination compared to conventional statistical approaches in predicting trauma death. The objective of this study is to evaluate whether machine learning algorithms can be used to assess risk and dynamically identify patient-specific modifiable factors critical to patient trajectory for multiple key outcomes after severe injury.
METHODS
SuperLearner, an ensemble machine-learning algorithm, was applied to prospective observational cohort data from 1494 critically-injured patients. Over 1000 agnostic predictors were used to generate prediction models from multiple candidate learners for outcomes of interest at serial time points post-injury. Model accuracy was estimated using cross-validation and area under the curve was compared to select among predictors. Clinical variables responsible for driving outcomes were estimated at each time point.
RESULTS
SuperLearner fits demonstrated excellent cross-validated prediction of death (overall AUC 0.94-0.97), multi-organ failure (overall AUC 0.84-0.90), and transfusion (overall AUC 0.87-0.9) across multiple post-injury time points, and good prediction of Acute Respiratory Distress Syndrome (overall AUC 0.84-0.89) and venous thromboembolism (overall AUC 0.73-0.83). Outcomes with inferior data quality included coagulopathic trajectory (AUC 0.48-0.88). Key clinical predictors evolved over the post-injury timecourse and included both anticipated and unexpected variables. Non-random missingness of data was identified as a predictor of multiple outcomes over time.
CONCLUSIONS
Machine learning algorithms can be used to generate dynamic prediction after injury while avoiding the risk of over- and under-fitting inherent in ad hoc statistical approaches. SuperLearner prediction after injury demonstrates promise as an adaptable means of helping clinicians integrate voluminous, evolving data on severely-injured patients into real-time, dynamic decision-making support.
Topics: Adult; Blood Transfusion; Clinical Decision-Making; Decision Support Techniques; Female; Humans; Machine Learning; Male; Middle Aged; Models, Biological; Multiple Organ Failure; Prognosis; Prospective Studies; ROC Curve; Respiratory Distress Syndrome; Risk Assessment; Time Factors; Venous Thromboembolism; Wounds and Injuries
PubMed: 30970030
DOI: 10.1371/journal.pone.0213836 -
BMC Cardiovascular Disorders Sep 2021MiR-92a-3p and oxidative stress are associated with catheter-related thrombosis (CRT). As a kind of physical intervention, resistance exercise can effectively promote...
BACKGROUND
MiR-92a-3p and oxidative stress are associated with catheter-related thrombosis (CRT). As a kind of physical intervention, resistance exercise can effectively promote blood circulation. In this study, we investigated the roles of miR-92a-3p, oxidative stress and the P38 mitogen-activated protein kinase/nuclear factor-κB (MAPK/NF-κB) pathway in CRT during resistance exercise.
METHODS
The rat CRT model was used for resistance exercise intervention. Moreover, pathological changes from the right jugular vein to the right auricle were observed under an electron microscope. In addition, reactive oxygen species (ROS) production, malondialdehyde (MDA) activity and heme oxygenase (HO-1) level in rat serum were detected via ELISA. The expression levels of miR-92A-3p and HO-1 in the vascular tissues of the rats were determined via real-time quantitative PCR. Additionally, the expression levels of HO-1, NF-κB P65, p38MAPK and IκBa in the venous tissues of the rats were analysed by Western blot analysis.
RESULTS
The pathological results showed that the thrombosis incidence rate in the CRT + RE group was lower than that in the CRT group. In the CRT group, the expression levels of ROS and MDA, which are markers related to oxidative stress in serum, significantly increased whilst the expression of HO-1 decreased. In the venous tissue, the expression of miR-92a-3p increased, the level of HO-1 decreased, the levels of p38MAPK and NF-κB p65 significantly increased but that of P-IκBa and IκBa significantly decreased. In the CRT + RE group, after administering the resistance exercise intervention, ROS production and MDA activity in serum significantly decreased, the expression level of HO-1 increased and the expression level of miR-92a-3p in the venous tissues significantly decreased and was negatively correlated with that of HO-1. The levels of p38MAPK and NF-κB p65 significantly decreased but that of P- IκBa and IκBa significantly increased.
CONCLUSION
Resistance exercise intervention downregulated miR-92a-3p expression, repaired oxidative stress injury and prevented CRT formation.
Topics: Animals; Blood Coagulation; Catheterization, Central Venous; Disease Models, Animal; Heme Oxygenase (Decyclizing); Jugular Veins; Male; MicroRNAs; NF-kappa B; Oxidative Stress; Rats, Sprague-Dawley; Resistance Training; Signal Transduction; Vascular System Injuries; Venous Thrombosis; p38 Mitogen-Activated Protein Kinases; Rats
PubMed: 34530722
DOI: 10.1186/s12872-021-02233-w -
Experimental and Clinical... Dec 2018We investigated the effects of autologous vein transplant on bile duct injury repair, through observation of the hepatic and biliary system tissue morphology changes and...
OBJECTIVES
We investigated the effects of autologous vein transplant on bile duct injury repair, through observation of the hepatic and biliary system tissue morphology changes and animal survival after bile duct injury repair.
MATERIALS AND METHODS
Rabbits were equally divided into groups. Group A had cholecystectomy and common bile duct resection (length of 0.5 cm), transplant of an autologous vein (length of 0.5 cm), and stent implant. Group B had cholecystectomy and common bile duct resection (length of 1.0 cm), transplant of an autologous vein (length of 1.0 cm), and stent implant. The third group (group C) had cholecystectomy only.
RESULTS
Two rabbits died in group A and group B; all experimental animals from group C survived. Regarding liver biochemical indexes at preoperative week 1, at postoperative month 1, and at postoperative month 3, we found no significant differences (paired t test, P > .05). Liver biochemical indexes between groups were also not significantly different (P > .05). At month 3, postoperative liver pathology of experimental animals showed no significant changes and no cholestasis; biliary epithelial cells were seen in the transplant vascular.
CONCLUSIONS
We conclude that autologous vein graft can effectively repair bile duct injury for a short coloboma.
Topics: Animals; Autografts; Cholecystectomy; Common Bile Duct; Disease Models, Animal; Male; Prosthesis Implantation; Rabbits; Stents; Time Factors; Veins; Wounds and Injuries
PubMed: 29025383
DOI: 10.6002/ect.2016.0309