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Shock (Augusta, Ga.) May 2021Recent studies have suggested the female hypercoaguable state may have a protective effect in trauma. However, whether this hypercoagulable profile confers a survival... (Comparative Study)
Comparative Study
INTRODUCTION
Recent studies have suggested the female hypercoaguable state may have a protective effect in trauma. However, whether this hypercoagulable profile confers a survival benefit in massively transfused trauma patients has yet to be determined. We hypothesized that females would have better outcomes than males after traumatic injury that required massive transfusion protocol (MTP).
PATIENTS AND METHODS
All trauma patients who underwent MTP at an urban, level 1, academic trauma center were reviewed from November 2007 to October 2018. Female MTP patients were compared to their male counterparts.
RESULTS
There were a total of 643 trauma patients undergoing MTP. Of these, 90 (13.8%) were female and 563 (86.2%) were male. Presenting blood pressure, heart rate, shock index, and injury severity score (ISS) were not significantly different. Overall mortality and incidence of venous thromboembolism were similar. Complication profile and hospital stay were similar. On logistic regression, female sex was not associated with survival (HR: 1.04, 95% CI: 0.56-1.92, P = 0.91). Variables associated with mortality included age (HR: 1.02, 95% CI: 1.05-1.09, P = 0.03) and ISS (HR: 1.07, 95% CI: 1.05-1.09, P < 0.001). Increasing Glascow Coma Scale was associated with survival (HR: 0.85, 95% CI: 0.82-0.89, P < 0.001). On subset analysis, premenopausal women (age < 50) did not have a survival advantage in comparison with similar aged males (HR: 0.68, 95% CI: 0.36-1.28, P = 0.24).
DISCUSSION
Sex differences in coagulation profile do not result in a survival advantage for females when MTP is required.
Topics: Adult; Blood Coagulation; Blood Transfusion; Female; Humans; Male; Middle Aged; Retrospective Studies; Sex Characteristics; Wounds and Injuries; Young Adult
PubMed: 32554993
DOI: 10.1097/SHK.0000000000001584 -
Acta Bio-medica : Atenei Parmensis Apr 2021Muscle in vein (MIV ) conduits have gradually been employed in the last 20 years as a valuable technique in bridging peripheral nerve gaps after nerve lesions who cannot...
Muscle in vein (MIV ) conduits have gradually been employed in the last 20 years as a valuable technique in bridging peripheral nerve gaps after nerve lesions who cannot undergo a direct tension-free coaptation. The advantages of this procedure comparing to the actual benchmark (autograft) is the sparing of the donor site, and the huge availability of both components (i.e. muscle and veins). Here we present a case serie of four MIV performed at our hospital from 2018 to 2019. The results we obtained in our experi-ence confirmed its effectiveness both in nerve regeneration (as sensibility recovery) and in neuropathic pain eradication. Our positive outcomes encourage its use in selected cases of residual nerve gaps up to 30 mm.
Topics: Humans; Muscles; Nerve Regeneration; Peripheral Nerve Injuries; Peripheral Nerves; Veins
PubMed: 33944845
DOI: 10.23750/abm.v92iS1.9202 -
Medicina (Kaunas, Lithuania) Aug 2022Background and Objectives: Retrograde free venous flaps represent a separate entity among free venous flaps: their physiology is still unclear, but they provide an...
Background and Objectives: Retrograde free venous flaps represent a separate entity among free venous flaps: their physiology is still unclear, but they provide an immediate visible refill after reconnection, with a similar behaviour to conventional flaps. Therefore, the dimensions and the indications of these flaps can be extended beyond what was previously believed, and they can be easily customized, including with respect to tendons and nerves. Nevertheless, they are still debated and regarded as unsafe. Materials and Methods: From 2012 to 2019, we performed 31 retrograde free venous flaps on 31 patients to reconstruct hands, digits, and in one case the heel. All the flaps were arterialized in a retrograde manner; the donor site was the forearm in 28 cases, the foot in 2 cases, and the calf in 1 case. We recorded the size, vein architecture, donor site, donor artery, donor morbidity, function for composite and non-composite flaps, immediate complications, late complications, survival rate, and the number of revisions. We recorded the hand function when appropriate. A total of 10 flaps were also intraoperatively studied with indocyanine green to monitor their hemodynamical behaviour. Results: All the patients were followed for an average of 8 months (6−15). The flap dimensions ranged from 6 cm2 to 136 cm2. All the flaps, except two that had complete necrosis, survived. Two flaps had partial necrosis. There was no correlation between necrosis and the size of the flap, with one case of necrosis and one of partial necrosis in the small flaps (<10 cm2). None of the cases with partial necrosis needed a new flap. Two flaps developed a late arterio-venous shunt that was ligated. Conclusions: The retrograde free venous flaps proved to be a useful tool for complex reconstructions of the hand and extremities. They can provide a large island of pliable skin and composite tissue with tendons and nerves, but surgeons must be aware of some caveats.
Topics: Forearm; Hand Injuries; Humans; Necrosis; Soft Tissue Injuries; Surgical Flaps; Veins
PubMed: 36013532
DOI: 10.3390/medicina58081065 -
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 -
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 -
Neurocritical Care Jun 2021This study investigates the presence of cerebrovascular injuries in a large sample of civilian penetrating brain injury (PBI) patients, determining the prevalence,...
BACKGROUND
This study investigates the presence of cerebrovascular injuries in a large sample of civilian penetrating brain injury (PBI) patients, determining the prevalence, radiographic characteristics, and impact on short-term outcome.
METHODS
We retrospectively reviewed patients with PBI admitted to our institution over a 2-year period. Computed tomography head scans, computer tomography angiograms and venograms of the intracranial vessels were evaluated to determine the wound trajectory, intracranial injury characteristics, and presence of arterial (AI) and venous sinus (VSI) injuries. Demographics, clinical presentation, and treatment were also reviewed. Discharge disposition was used as surrogate of short-term outcome.
RESULTS
Seventy-two patients were included in the study. The mechanism of injury was gunshot wounds in 71 patients and stab wound in one. Forty-one of the 72 patients (60%) had at least one vascular injury. Twenty-six out of 72 patients suffered an AI (36%), mostly pseudoaneurysms and occlusions, involving the anterior and middle cerebral arteries. Of the 72 patients included, 45 had dedicated computed tomography venograms, and of those 22 had VSI (49%), mainly manifesting as superior sagittal sinus occlusion. In a multivariable regression model, intraventricular hemorrhage at presentation was associated with AI (OR 9.9, p = 0.004). The same was not true for VSI.
CONCLUSION
Acute traumatic cerebrovascular injury is a prevalent complication in civilian PBI, frequently involving both the arterial and venous sinus systems. Although some radiographic features might be associated with presence of vascular injury, assessment of the intracranial vasculature in the acute phase of all PBI is essential for early diagnosis. Treatment of vascular injury remains variable depending on local practice.
Topics: Head Injuries, Penetrating; Humans; Retrospective Studies; Survivors; Tomography, X-Ray Computed; Wounds, Gunshot
PubMed: 33025542
DOI: 10.1007/s12028-020-01106-y -
Journal of Vascular Surgery. Venous and... Mar 2022Percutaneous endovenous stenting has emerged during the past decade as the primary method of treating symptomatic venous outflow obstruction. A recognized complication...
BACKGROUND
Percutaneous endovenous stenting has emerged during the past decade as the primary method of treating symptomatic venous outflow obstruction. A recognized complication of venous stenting is stent migration. The aim of the present systematic review was to identify the number of cases of stent migration in reported studies to recognize the risk factors that might be associated with this complication and the outcomes following migration.
METHODS
A review was conducted in accordance with the MOOSE (meta-analyses of observational studies in epidemiology) and PRIMSA (preferred reporting items for systematic review and meta-analysis) guidelines and registered in the PROSPERO. MEDLINE, EMBASE, and PubMed databases. Key references were searched using specified keywords. All relevant data for the primary procedure and subsequent presentation with stent migration were retrieved. The data were assessed as too low in quality to allow for statistical analysis.
RESULTS
Between 1994 and 2020, 31 studies were identified, including 29 case reports and 2 case series, providing data for 54 events of venous stent migration with some data provided regarding the stent used for 47 of the events. The mean age of the 52 patients with stent migration was 50 years (range, 19-88 years) and 30 were men (57.6%). The stents for most of the reported cases were ≤60 mm in length (38 of 46; 82.6%). Only three of the reports were of stents >14 mm in diameter (3 of 47; 3.6%). None of the studies had reported migration of stents >100 mm long. In 85% of the migrated stent events, retrieval was attempted, with 65.2% via an endovascular approach. The immediate outcome was satisfactory for 100% of the reported attempts, whether by an endovascular or open surgical approach.
CONCLUSIONS
The findings from our literature review suggest that the risk of migration is rare but might be underreported. Most of reported cases had occurred with shorter and smaller diameter stents. The paucity of reported data and the short-term follow-up provided suggest that more formal data collection would provide a truer reflection of the incidence. However, clear strategies to avoid migration should be followed to prevent this complication from occurring.
Topics: Adult; Aged; Aged, 80 and over; Device Removal; Endovascular Procedures; Female; Foreign-Body Migration; Humans; Incidence; Male; Middle Aged; Risk Assessment; Risk Factors; Stents; Treatment Outcome; Veins; Young Adult
PubMed: 35026448
DOI: 10.1016/j.jvsv.2021.07.015 -
Journal of Vascular Surgery. Venous and... May 2020
Topics: Humans; Phlebography; Ultrasonography, Interventional; Vascular Diseases; Vascular Surgical Procedures; Veins
PubMed: 33371987
DOI: 10.1016/j.jvsv.2020.03.009 -
The Journal of Trauma and Acute Care... Feb 2023Thromboelastography (TEG)-derived maximum amplitude-reaction time (MA-R) ratio that accounts for both hypocoagulable and hypercoagulable changes in coagulation is...
INTRODUCTION
Thromboelastography (TEG)-derived maximum amplitude-reaction time (MA-R) ratio that accounts for both hypocoagulable and hypercoagulable changes in coagulation is associated with poor outcomes in adults. The relationship between these TEG values and outcomes has not been studied in children.
METHODS
In a retrospective cohort study, a level I pediatric trauma center database was queried for children younger than 18 years who had a TEG assay on admission between 2016 and 2020. Demographics, injury characteristics, and admission TEG values were recorded. The MA-R ratio was calculated and divided into quartiles. Main outcomes included mortality, transfusion within 24 hours of admission, and thromboembolism. A logistic regression model was generated adjusting for age, Injury Severity Score, injury mechanism, admission shock, and Glasgow Coma Scale.
RESULTS
In total, 657 children were included, of which 70% were male and 75% had blunt mechanism injury. The median (interquartile range) age was 11 (4-14) years, the median (interquartile range) Injury Severity Score was10 (5-22), and in-hospital mortality was 7% (n = 45). Of these patients, 17% (n = 112) required transfusion. Most R and MA values were within normal limits. On unadjusted analysis, the lowest MA-R ratio quartile was associated with increased mortality (15% vs. 4%, 5%, and 4%, respectively; p < 0.001) and increased transfusion need (26% vs. 12%, 16%, and 13%, respectively; p = 0.002) compared with higher quartiles. In the logistic regression models, a low MA-R ratio was independently associated with increased in-hospital mortality (odds ratio [95% confidence interval], 4.4 [1.9-10.2]) and increased need for transfusion within 24 hours of admission (odds ratio [95% confidence interval], 2.0 [1.2-3.4]) compared with higher MA-R ratio. There was no association between MA-R ratio and venous thromboembolic events (venous thromboembolic event rate by quartile: 4%, 2%, 1%, and 3%).
CONCLUSION
Although individual admission TEG values are not commonly substantially deranged in injured children, the MA-R ratio is an independent predictor of poor outcome. Maximum amplitude-reaction time ratio may be a useful prognostic tool in pediatric trauma; validation is necessary.
LEVEL OF EVIDENCE
Therapeutic/Care Management; Level III.
Topics: Adult; Humans; Male; Child; Adolescent; Female; Thrombelastography; Retrospective Studies; Reaction Time; Thrombophilia; Venous Thromboembolism; Injury Severity Score; Wounds and Injuries; Blood Coagulation Disorders
PubMed: 36694332
DOI: 10.1097/TA.0000000000003834 -
Heart and Vessels May 2022Radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) causes myocardial injury and induces high-sensitive cardiac troponin I (hs-TnI) release into the...
Radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) causes myocardial injury and induces high-sensitive cardiac troponin I (hs-TnI) release into the systemic circulation. Several factors are considered to be associated with myocardial injury after ablation, but few studies showed the relationship between the value of myocardial injury marker after the RFCA and relevant factors. AF patients who underwent primary RFCA were enrolled from the Osaka Rosai Atrial Fibrillation ablation (ORAF) registry. The relationship between hs-TnI after the RFCA and PV reconnection (PVR) was evaluated. The impact of relevant factors, including baseline patient characteristics, detail of procedure on myocardial injury was investigated. This study included 407 patients (median age was 71 years, the ratio of female was 30.7%). Late arrhythmia recurrence was observed in 111 patients (27.3%) and 66 patients were underwent repeated ablation. PVR was observed in 33 patients (50.0%). The hs-TnI level was significantly lower in the patients with PVR than those without PVR (1.150 ng/ml vs 1.921 ng/ml, p = 0.040). Paroxysmal AF and age were significantly associated with acute myocardial injury after the RFCA (standardized beta coefficient = 0.206 and p < 0.001, standardized beta coefficient = - 0.114 and p = 0.043, respectively). The hs-TnI after RFCA was significantly higher in PAF patients than PerAF (p < 0.001), even if application number and total application time were taken into consideration. Acute myocardial injury after RFCA was significantly lower in the patients with PVR than those without PVR. Age and AF type were significantly and strongly associated with acute myocardial injury after the RFCA.
Topics: Aged; Atrial Fibrillation; Catheter Ablation; Female; Heart Injuries; Humans; Pulmonary Veins; Recurrence; Treatment Outcome
PubMed: 34668989
DOI: 10.1007/s00380-021-01972-2