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The American Surgeon Aug 2023Gunshot wounds account for significant morbidity and mortality in the United States. A rare and potentially fatal complication of a gunshot wound is bullet embolus....
Gunshot wounds account for significant morbidity and mortality in the United States. A rare and potentially fatal complication of a gunshot wound is bullet embolus. Potential complications include distal limb ischemia, coronary infarct, renal infarction, stroke, pulmonary embolization, cardiac valvular injury, thrombophlebitis, and dysrhythmias. Overall, surgical embolectomy and endovascular retrieval are the preferred treatments for bullet emboli. We report one case of venous bullet embolus and one case of arterial bullet embolus, both of which were successfully treated with endovascular retrieval. A thorough physical exam and appropriate imaging are vital to prompt identification and treatment of bullet emboli, as the repercussions of missed injuries can be devastating.
Topics: Humans; Wounds, Gunshot; Embolism; Veins; Embolectomy; Heart Injuries; Foreign-Body Migration
PubMed: 36960753
DOI: 10.1177/00031348231167413 -
Angiogenesis May 2021Endothelial cells display an extraordinary plasticity both during development and throughout adult life. During early development, endothelial cells assume arterial,... (Review)
Review
Endothelial cells display an extraordinary plasticity both during development and throughout adult life. During early development, endothelial cells assume arterial, venous, or lymphatic identity, while selected endothelial cells undergo additional fate changes to become hematopoietic progenitor, cardiac valve, and other cell types. Adult endothelial cells are some of the longest-lived cells in the body and their participation as stable components of the vascular wall is critical for the proper function of both the circulatory and lymphatic systems, yet these cells also display a remarkable capacity to undergo changes in their differentiated identity during injury, disease, and even normal physiological changes in the vasculature. Here, we discuss how endothelial cells become specified during development as arterial, venous, or lymphatic endothelial cells or convert into hematopoietic stem and progenitor cells or cardiac valve cells. We compare findings from in vitro and in vivo studies with a focus on the zebrafish as a valuable model for exploring the signaling pathways and environmental cues that drive these transitions. We also discuss how endothelial plasticity can aid in revascularization and repair of tissue after damage- but may have detrimental consequences under disease conditions. By better understanding endothelial plasticity and the mechanisms underlying endothelial fate transitions, we can begin to explore new therapeutic avenues.
Topics: Animals; Arteries; Cell Differentiation; Endothelial Cells; Hematopoietic Stem Cells; Humans; Lymphatic Vessels; Neovascularization, Physiologic; Veins; Wounds and Injuries; Zebrafish
PubMed: 33449300
DOI: 10.1007/s10456-020-09761-7 -
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 -
Abdominal Radiology (New York) Mar 2023Non-operative management of hepatic trauma with adjunctive hepatic arterial embolization (HAE) is widely accepted. Despite careful patient selection utilizing CTA, a...
PURPOSE
Non-operative management of hepatic trauma with adjunctive hepatic arterial embolization (HAE) is widely accepted. Despite careful patient selection utilizing CTA, a substantial proportion of angiograms are negative for arterial injury and no HAE is performed. This study aims to determine which CT imaging findings and clinical factors are associated with the presence of active extravasation on subsequent angiography in patients with hepatic trauma.
MATERIALS AND METHODS
The charts of 243 adults who presented with abdominal trauma and underwent abdominal CTA followed by conventional angiography were retrospectively reviewed. Of these patients, 49 had hepatic injuries on CTA. Hepatic injuries were graded using the American association for the surgery of trauma (AAST) CT classification, and CT images were assessed for active contrast extravasation, arterial pseudoaneurysm, sentinel clot, hemoperitoneum, laceration in-volving more than 2 segments, and laceration involving specific anatomic landmarks (porta hepatis, hepatic veins, and gallbladder fossa). Medical records were reviewed for pre- and post-angiography blood pressures, hemoglobin levels, and transfusion requirements. Angiographic images and reports were reviewed for hepatic arterial injury and performance of HAE.
RESULTS
In multivariate analysis, AAST hepatic injury grade was significantly associated with increased odds of HAE (Odds ratio: 2.5, 95% CI 1.1, 7.1, p = 0.049). Univariate analyses demonstrated no significant association between CT liver injury grade, CT characteristics of liver injury, or pre-angiographic clinical data with need for HAE.
CONCLUSION
In patients with hepatic trauma, prediction of need for HAE based on CT findings alone is challenging; such patients require consideration of both clinical factors and imaging findings.
Topics: Adult; Humans; Lacerations; Retrospective Studies; Wounds, Nonpenetrating; Liver; Hepatic Artery; Embolization, Therapeutic
PubMed: 36520161
DOI: 10.1007/s00261-022-03765-1 -
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 -
Journal of Vascular Surgery. Venous and... Nov 2021Venous injury to the inferior vena cava or iliac veins is rare but can result in high mortality rates. Traditional treatment by repair or ligation can be technically...
OBJECTIVE
Venous injury to the inferior vena cava or iliac veins is rare but can result in high mortality rates. Traditional treatment by repair or ligation can be technically demanding. A relatively new treatment modality is the use of a covered stent to cover the venous defect. The aim of the present systematic review was to assess the techniques, results, and challenges of covered stent graft repair of traumatic injury to the inferior vena cava and iliac veins.
METHODS
The PubMed (Medline) and Embase databases were systematically searched up to September 2020 by two of us (R.R.S. and D.D.) independently for studies reporting on covered stenting of the inferior vena cava or iliac veins after traumatic or iatrogenic injury. A methodologic quality assessment was performed using the modified Newcastle-Ottawa scale. Data were extracted for the following parameters: first author, year of publication, study design, number of patients, type and diameter of the stent graft, hemostatic success, complications, mortality, postoperative medication, follow-up type and duration, and venous segment patency. The main outcome was clinical success of the intervention, defined as direct hemostasis, with control of hemorrhage, hemodynamic recovery, and absence of contrast extravasation.
RESULTS
From the initial search, which yielded 1884 records, a total of 28 studies were identified for analysis. All reports consisted of case reports, except for one retrospective cohort study and one case series. A total of 35 patients had been treated with various covered stent grafts, predominantly thoracic or abdominal aortic endografts. In all patients, the treatment was technically successful. The 30-day mortality rate for the entire series was 2.9%. Three perioperative complications were described: one immediate stent occlusion, one partial thrombosis, and one pulmonary embolism. Additional in-stent thrombus formation was seen during follow-up in three patients, leading to one stent graft occlusion (asymptomatic). The postoperative anticoagulation strategy was highly heterogeneous. The median follow-up was 3 months (range, 0.1-84 months). However, follow-up with imaging studies was not performed in all cases.
CONCLUSIONS
In selected cases of injury to the inferior vena cava and iliac veins, covered stent grafts can be successful for urgent hemostasis with good short-term results. Data on long-term follow-up are very limited.
Topics: Humans; Iliac Vein; Prosthesis Design; Stents; Vascular Surgical Procedures; Vena Cava, Inferior
PubMed: 33771733
DOI: 10.1016/j.jvsv.2021.03.008 -
Interventional Neuroradiology : Journal... Jun 2023Coil embolization is the mainstay treatment for carotid-cavernous fistulas (CCFs). However, few studies have reported entire occlusion of engorged veins to interrupt...
BACKGROUND
Coil embolization is the mainstay treatment for carotid-cavernous fistulas (CCFs). However, few studies have reported entire occlusion of engorged veins to interrupt venous outflow. We report our experience with venous outflow-targeted coil embolization of direct CCFs.
METHODS
We retrospectively reviewed all the patients diagnosed with direct CCFs treated with venous outflow-targeted coil embolization between November 2013 and February 2020. Venous outflow-targeted coil embolization of the CCFs was performed as follows. First, transarterial stent-assisted coil embolization of CCFs was performed. If the venous outflow to the engorged veins persisted after transarterial stent-assisted coil embolization, entire occlusion of the engorged veins and additional coil packing within the cavernous sinus were performed to interrupt the venous outflow.
RESULTS
Ten patients had undergone venous outflow-targeted coil embolization, 6 women (60%) and 4 men (40%). Transfemoral cerebral angiography showed high-flow, direct CCFs in all the patients. Venous outflow occurred through the superior ophthalmic vein (SOV) in all the patients and was completely interrupted by the entire occlusion of the engorged veins with fibered coils. Three patients (30%) had undergone additional treatment in a supplementary manner because of recurrent symptoms (chemosis in 1 patient, faint tinnitus in 2 patients) in the early postprocedural period (1 to 4 weeks). All the symptoms were resolved on follow-up. No additional recurrence was found during follow-up (1-75 months). No peri-procedural complications were encountered.
CONCLUSIONS
Venous outflow-targeted coil embolization of CCFs would be a safe and effective treatment method.
Topics: Male; Humans; Female; Retrospective Studies; Carotid-Cavernous Sinus Fistula; Cavernous Sinus; Veins; Treatment Outcome; Embolization, Therapeutic
PubMed: 35238235
DOI: 10.1177/15910199221084787 -
Clinical Otolaryngology : Official... Jan 2022To report the experience of civilian penetrating neck trauma (PNT) at a UK level I trauma centre, propose an initial management algorithm and assess the degree of...
OBJECTIVES
To report the experience of civilian penetrating neck trauma (PNT) at a UK level I trauma centre, propose an initial management algorithm and assess the degree of correlation between clinical signs of injury, operative findings and radiological reports.
DESIGN
Retrospective case note review.
SETTING
UK level I trauma centre April 2012-November 2017.
PARTICIPANTS
Three hundred ten cases of PNT were drawn from electronic patient records. Data were extracted on hard and soft signs of vascular or aerodigestive tract injury, clinical management, radiological imaging and patient outcomes.
MAIN OUTCOME MEASURES
Patient demographics, mechanism of injury, morbidity and mortality. The correlation between clinical signs, and radiological reports to internal injury on surgical exploration.
RESULTS
Two hundred seventy-one (87.4%) male and 39 (13.6%) female patients with a mean age of 36 years (16-87) were identified. The most common causes of injury were assault 171 (55.2%) and deliberate self-harm 118 (38%). A knife was the most common instrument 240 (77.4%). Past psychiatric history was noted in 119 (38.4%), and 60 (19.4%) were intoxicated. 50% were definitively managed in theatre with a negative exploration rate of 38%, and 50% were managed in ED. Pre-operative radiological reports correlated with operative reports in 62% of cases with venous injury the most common positive and negative finding. Multivariate correlation was r = 0.89, p = 0.045, between hard signs plus positive radiology findings and internal injury on neck exploration.
CONCLUSIONS
Management of PNT by clinical and radiological signs is safe and effective, and can be streamlined by a decision-making algorithm as proposed here.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Algorithms; Female; Humans; Male; Middle Aged; Neck Injuries; Retrospective Studies; Tomography, X-Ray Computed; Trauma Centers; United Kingdom; Wounds, Penetrating; Young Adult
PubMed: 34323008
DOI: 10.1111/coa.13841 -
Nigerian Journal of Clinical Practice Sep 2020: Vascular injuries are commonly seen in both emergency services and forensic medicine practise. They are often life-threatening, with high morbidity and mortality rates.
BACKGROUND
: Vascular injuries are commonly seen in both emergency services and forensic medicine practise. They are often life-threatening, with high morbidity and mortality rates.
AIMS
This study aimed to retrospectively evaluate extremity vascular injuries and the associated treatment approaches.
METHODS
After obtaining approval from the ethics committee of the university, those patients admitted to the emergency department of Adiyaman between 1 February 2013 and 31 August 2018 were included in this study. The patients' data were obtained through the electronic records system, and the cases were evaluated according to the age, gender and cause of injury, including blunt force trauma injuries (accidents, traffic accidents, crush injuries and occupational accidents) and penetrating injuries (stabbing, gunshot wounds, suicide attempts and assaults). Additionally, the injuries were evaluated based on the extremity, according to the anatomical location and whether the injury was life-threatening.
RESULTS
This study included 76 patients with extremity vascular injuries; 65 were males (85.52%), 11 were females (14.48%) and their average age was 33.24 ± 15.85 years. Forty-five (59.2%) of the patients had upper extremity vascular injuries, and 31 (40.3%) had lower extremity vascular injuries. In addition to arterial injuries, 26 (34.21%) of the patients had venous injuries and 22 (28.94%) had nerve injuries. Nine of these patients had neurological deficits due to their nerve injuries. All of the patients were revascularized within 3-5 hours, and none of the patients required amputations.
CONCLUSION
The primary goals in extremity vessel injury cases are to prevent mortality, especially after major vascular injuries, and save the extremity from amputation. With a fast, effective and multi-disciplinary approach, an accurate diagnosis and effective surgical intervention can prevent morbidity and mortality as well as reduce the rate of undesirable complications.
Topics: Accidents, Traffic; Adolescent; Adult; Arteries; Computed Tomography Angiography; Extremities; Female; Humans; Lower Extremity; Male; Middle Aged; Retrospective Studies; Treatment Outcome; Vascular Surgical Procedures; Vascular System Injuries; Wounds, Gunshot; Wounds, Nonpenetrating; Wounds, Penetrating; Young Adult
PubMed: 32913160
DOI: 10.4103/njcp.njcp_656_18 -
The Journal of Invasive Cardiology Jul 2022To examine the incidence, treatment and outcomes of perforation during percutaneous coronary intervention (PCI).
OBJECTIVES
To examine the incidence, treatment and outcomes of perforation during percutaneous coronary intervention (PCI).
BACKGROUND
Coronary perforation is a potentially life-threatening PCI complication.
METHODS
We examined the clinical, angiographic, and procedural characteristics, management, and outcomes of coronary perforation at a tertiary care institution.
RESULTS
Between 2014 and 2019, perforation occurred in 70 of 10,278 PCIs (0.7%). Patient age was 71 ± 12 years, 66% were men, and 30% had prior coronary artery bypass graft surgery. Among perforation cases, the prevalence of chronic total occlusions was 33%, moderate/severe calcification was 66% and moderate/severe tortuosity was 41%. The frequency of Ellis class 1, 2, and 3 perforations was 14%, 50%, and 36%, respectively. Most (n = 51; 73%) were large vessel perforations, 16 (23%) were distal vessel perforations and 3 (4%) were collateral vessel perforations (1 septal and 2 epicardial). Hypotension occurred in 26%, pericardial effusion in 36% and tamponade in 13%; 47% of perforations did not have clinical consequences. Perforations were most often treated with prolonged balloon inflation (63%), reversal of anticoagulation (39%), and covered stent implantation (33%). Technical and procedural success were 73% and 60%, respectively, and major periprocedural adverse cardiac events occurred in 21% of the patients. Three patients (4%) required emergent CABG surgery and four (6%) died.
CONCLUSIONS
Coronary perforation is an infrequent complication of PCI. Most perforations are large vessel perforations and often require further intervention. The incidence of death or emergent cardiac surgery is low.
Topics: Aged; Aged, 80 and over; Coronary Angiography; Coronary Vessels; Female; Heart Injuries; Humans; Incidence; Male; Middle Aged; Percutaneous Coronary Intervention; Treatment Outcome; Vascular System Injuries
PubMed: 35714223
DOI: No ID Found