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Journal of Vascular Surgery May 2012Blunt abdominal aortic injury (BAAI) is a rare injury with less than 200 cases in the current reported world literature, mostly in case report format. We sought to... (Review)
Review
BACKGROUND
Blunt abdominal aortic injury (BAAI) is a rare injury with less than 200 cases in the current reported world literature, mostly in case report format. We sought to describe the experience of a high-volume trauma center and to provide a contemporary review of the literature to better understand the natural history and management of this injury.
METHODS
This was a retrospective review of patients with BAAI between 1996 and 2010. Data collected included demographics, mechanism of injury, associated injuries, type of intervention, subsequent imaging, and follow-up. BAAI was classified by the presence of external aortic contour abnormality noted as an intimal tear, large intimal flap, pseudoaneurysm, or free rupture. Abdominal aorta zones of injury were classified by possible surgical approaches as zone I (diaphragmatic hiatus to superior mesenteric artery [SMA]), zone II (includes SMA and renal arteries), and zone III (from the inferior aspect of the renal arteries to the aortic bifurcation).
RESULTS
We identified 28 individuals (68% male) with BAAI (median age, 28.5; range, 6-61 years). The median injury severity score was 45 (range, 16-75), and 39% were hypotensive at presentation. BAAI presented as intimal tear (21%), large intimal flap (39%), pseudoaneurysm (11%), and free rupture (29%). Zone III was the most common location of injury. Management depended on the location and type of injury: nonoperative (32%), open aortic repair (36%), endovascular repair (21%), and multimodality (10%). Overall mortality was 32%. Most deaths occurred during the initial operative exploration. The mortality rate of free aortic rupture was 100%. Intimal tears resolved or remained stable. Median follow-up was 15.5 months (range, 8 days-7.5 years). Vascular complications due to repair included a thrombosed access femoral artery during an endovascular repair and death of a patient who underwent a hybrid repair.
CONCLUSIONS
This is the largest BAAI series described in the English literature at one institution. BAAIs range from intimal tears to free rupture, with outcomes and management correlating with type and location of injury. Nonoperative management with blood pressure control using β-blockers coupled with antiplatelet therapy and close follow-up is successful in individuals with intimal tears with minimal thrombus formation because they remain stable or resolve on follow-up. Free rupture remains a devastating injury, with 100% mortality. For all other categories of aortic injury, successful repair correlates with a favorable prognosis.
Topics: Adolescent; Adult; Aneurysm, False; Aorta, Abdominal; Aortic Aneurysm; Aortic Diseases; Aortic Rupture; Aortography; Cardiovascular Agents; Child; Endovascular Procedures; Female; Humans; Incidence; Male; Middle Aged; Predictive Value of Tests; Retrospective Studies; Severity of Illness Index; Time Factors; Tomography, X-Ray Computed; Treatment Outcome; Vascular Surgical Procedures; Vascular System Injuries; Washington; Wounds, Nonpenetrating; Young Adult
PubMed: 22322120
DOI: 10.1016/j.jvs.2011.10.132 -
Journal of the American Heart... Jul 2020Background Arterial restenosis after vascular surgery is a common cause of midterm restenosis and treatment failure. Herein, we aim to investigate the role of...
Microbe-Derived Butyrate and Its Receptor, Free Fatty Acid Receptor 3, But Not Free Fatty Acid Receptor 2, Mitigate Neointimal Hyperplasia Susceptibility After Arterial Injury.
Background Arterial restenosis after vascular surgery is a common cause of midterm restenosis and treatment failure. Herein, we aim to investigate the role of microbe-derived butyrate, FFAR2 (free fatty acid receptor 2), and FFAR3 (free fatty acid receptor 3) in mitigating neointimal hyperplasia development in remodeling murine arteries after injury. Methods and Results C57BL/6 mice treated with oral vancomycin before unilateral femoral wire injury to deplete gut microbiota had significantly diminished serum and stool butyrate and more neointimal hyperplasia development after arterial injury, which was reversed by concomitant butyrate supplementation. Deficiency of FFAR3 but not FFAR2, both receptors for butyrate, exacerbated neointimal hyperplasia development after injury. FFAR3 deficiency was also associated with delayed recovery of the endothelial layer in vivo. FFAR3 gene expression was observed in multiple peripheral arteries, and expression was increased after arterial injury. Treatment of endothelial but not vascular smooth muscle cells with the pharmacologic FFAR3 agonist 1-methylcyclopropane carboxylate stimulated cellular migration and proliferation in scratch assays. Conclusions Our results support a protective role for butyrate and FFAR3 in the development of neointimal hyperplasia after arterial injury and delineate activation of the butyrate-FFAR3 pathway as a valuable strategy for the prevention and treatment of neointimal hyperplasia.
Topics: Animals; Anti-Bacterial Agents; Bacteria; Butyric Acid; Cell Movement; Cell Proliferation; Disease Models, Animal; Femoral Artery; Gastrointestinal Microbiome; Hyperplasia; Mice, Inbred C57BL; Mice, Knockout; Neointima; Receptors, G-Protein-Coupled; Signal Transduction; Vancomycin; Vascular System Injuries
PubMed: 32580613
DOI: 10.1161/JAHA.120.016235 -
Journal of Vascular Surgery Aug 2019Sport-related vascular trauma is an important consequence of increased physical activity. Repetitive, high-intensity movements predispose athletes to vascular disease,... (Review)
Review
BACKGROUND/OBJECTIVE
Sport-related vascular trauma is an important consequence of increased physical activity. Repetitive, high-intensity movements predispose athletes to vascular disease, including arterial pathology, by exerting increased pressure on neurovascular structures. This is an important source of morbidity in an otherwise young and healthy population. Arterial pathology associated with repetitive trauma is often misdiagnosed as musculoskeletal injury. This article increases awareness of sport-related arterial disease by reviewing the symptomatology, investigation, and treatment modalities of this pathology. In addition, prognostic outcomes specific to the athlete are discussed.
RESULTS
Arterial thoracic outlet syndrome and vascular quadrilateral space syndrome are associated with athletes involved in overhead throwing exercises. Sport-related arterial pathology of the lower limb include external iliac artery endofibrosis (EIAE), popliteal artery entrapment syndrome (PAES), and adductor canal syndrome. Vascular stress and kinking secondary to vessel tethering are important contributors to pathology in EIAE. Chronic exertional compartment syndrome must also be considered, presenting with clinical features similar to PAES. In addition, athletes are predisposed to blunt mechanical trauma. Hypothenar hammer syndrome is one such example, contributing to a high burden of morbidity in this population.
CONCLUSIONS
In arterial thoracic outlet syndrome and vascular quadrilateral space syndrome, surgery is advocated in symptomatic individuals, with postoperative outcomes favorable for the athlete. Acute limb ischemia may occur as a result of secondary thrombosis or embolization, often without preceding claudication. PAES and adductor canal syndrome are associated with functional entrapment in the athlete, secondary to muscular hypertrophy. Surgical exploration may be indicated. Poorer outcomes are noted when this process is associated with vascular reconstruction. Surgical treatment of EIAE follows failure of conservative management, with limited data available on postoperative prognosis. Investigations for all these conditions should be targeted based on clinical suspicion. A delay in diagnosis can have severe consequences on return to competition in these high-functioning individuals.
Topics: Arteries; Athletes; Athletic Injuries; Humans; Recovery of Function; Return to Sport; Risk Factors; Treatment Outcome; Vascular System Injuries
PubMed: 31113722
DOI: 10.1016/j.jvs.2019.02.002 -
VASA. Zeitschrift Fur Gefasskrankheiten Mar 2023Vascular handlebar syndrome with blunt injury of the common femoral artery is a rare vascular trauma mechanism, with high possibility of being missed or delayed. We... (Review)
Review
Vascular handlebar syndrome with blunt injury of the common femoral artery is a rare vascular trauma mechanism, with high possibility of being missed or delayed. We present two cases of vascular handlebar syndrome treated in our hospital and a systematic review of the literature using MEDLINE and SCOPUS databases. Literature review identified 20 similar cases. The median age of patients was 18 years, and in vast majority males in gender. In most cases, the common femoral artery injury was an intimal flap and lumen occlusion with intramural thrombosis followed by transection and intimal injury without occlusion or thrombosis. The median time between injury and diagnosis/treatment was half an hour. Clinical presentation ranged from asymptomatic to acute limb ischemia. The grade of acute ischemia was mostly Rutherford class I (n=14), while acute IIa (n=4), chronic ischemia (n=3), and no ischemia (n=1) were also noticed. The correct diagnosis was revealed by clinical examination only (n=1), or by the combination of clinical and imaging techniques including computed tomography angiography (n=7) and duplex ultrasonography (n=4) or both (n=10). Management of the handlebar trauma syndrome injuries was surgical in most cases. Outcome was favorable in all patients. Vascular handlebar syndrome is extremely rare and high suspicion is required for early diagnosis and definitive treatment, as the early management is effective and crucial for averting the devastating consequences. An individualized approach to the vascular trauma patient is to be applied with considerations taken to the age of the patient, the mechanism of the injury, the anatomy of the lesion, and symptomatology of the case.
Topics: Adolescent; Humans; Male; Femoral Artery; Ischemia; Thrombosis; Tomography, X-Ray Computed; Vascular System Injuries; Wounds, Nonpenetrating
PubMed: 36698255
DOI: 10.1024/0301-1526/a001054 -
Cerebrovascular Diseases Extra 2017Ischemic stroke occurs in a significant subset of patients with blunt traumatic cerebrovascular injury (TCVI). The patients are victims of motor vehicle crashes,... (Review)
Review
BACKGROUND
Ischemic stroke occurs in a significant subset of patients with blunt traumatic cerebrovascular injury (TCVI). The patients are victims of motor vehicle crashes, assaults or other high-energy collisions, and suffer ischemic stroke due to injury to the extracranial carotid or vertebral arteries.
SUMMARY
An increasing number of patients with TCVI are being identified, largely because of the expanding use of computed tomography angiography for screening patients with blunt trauma. Patients with TCVI are particularly challenging to manage because they often suffer polytrauma, that is, numerous additional injuries including orthopedic, chest, abdominal, and head injuries. Presently, there is no consensus about optimal management. Key Messages: Most literature about TCVI and stroke has been published in trauma, general surgery, and neurosurgery journals; because of this, and because these patients are managed primarily by trauma surgeons, patients with stroke due to TCVI have been essentially hidden from view of neurologists. This review is intended to bring this clinical entity to the attention of clinicians and investigators with specific expertise in neurology and stroke.
Topics: Brain Ischemia; Carotid Artery Injuries; Cerebral Angiography; Computed Tomography Angiography; Humans; Predictive Value of Tests; Prognosis; Risk Assessment; Risk Factors; Stroke; Vascular System Injuries; Vertebral Artery; Wounds, Nonpenetrating
PubMed: 28399527
DOI: 10.1159/000455391 -
Academic Emergency Medicine : Official... Aug 2017Penetrating Extremity Trauma (PET) may result in arterial injury, a rare but limb- and life-threatening surgical emergency. Timely, accurate diagnosis is essential for... (Meta-Analysis)
Meta-Analysis Review
Accuracy of Physical Examination, Ankle-Brachial Index, and Ultrasonography in the Diagnosis of Arterial Injury in Patients With Penetrating Extremity Trauma: A Systematic Review and Meta-analysis.
BACKGROUND
Penetrating Extremity Trauma (PET) may result in arterial injury, a rare but limb- and life-threatening surgical emergency. Timely, accurate diagnosis is essential for potential intervention in order to prevent significant morbidity.
OBJECTIVES
Using a systematic review/meta-analytic approach, we determined the utility of physical examination, Ankle-Brachial Index (ABI), and Ultrasonography (US) in the diagnosis of arterial injury in emergency department (ED) patients who have sustained PET. We applied a test-treatment threshold model to determine which evaluations may obviate CT Angiography (CTA).
METHODS
We searched PubMed, Embase, and Scopus from inception to November 2016 for studies of ED patients with PET. We included studies on adult and pediatric subjects. We defined the reference standard to include CTA, catheter angiography, or surgical exploration. When low-risk patients did not undergo the reference standard, trials must have specified that patients were observed for at least 24 hours. We used the Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) to evaluate bias and applicability of the included studies. We calculated positive and negative likelihood ratios (LR+ and LR-) of physical examination ("hard signs" of vascular injury), US, and ABI. Using established CTA test characteristics (sensitivity = 96.2%, specificity = 99.2%) and applying the Pauker-Kassirer method, we developed a test-treatment threshold model (testing threshold = 0.14%, treatment threshold = 72.9%).
RESULTS
We included eight studies (n = 2,161, arterial injury prevalence = 15.5%). Studies had variable quality with most at high risk for partial and double verification bias. Some studies investigated multiple index tests: physical examination (hard signs) in three studies (n = 1,170), ABI in five studies (n = 1,040), and US in four studies (n = 173). Due to high heterogeneity (I > 75%) of the results, we could not calculate LR+ or LR- for hard signs or LR+ for ABI. The weighted prevalence of arterial injury for ABI was 14.3% and LR- was 0.59 (95% confidence interval [CI] = 0.48-0.71) resulting in a posttest probability of 9% for arterial injury. Ultrasonography had weighted prevalence of 18.9%, LR+ of 35.4 (95% CI = 8.3-151), and LR- of 0.24 (95% CI = 0.08-0.72); posttest probabilities for arterial injury were 89% and 5% after positive or negative US, respectively. The posttest probability of arterial injury with positive US (89%) exceeded the CTA treatment threshold (72.9%). The posttest probabilities of arterial injury with negative US (5%) and normal ABI (9%) exceeded the CTA testing threshold (0.14%). Normal examination (no hard or soft signs) with normal ABI in combination had LR- of 0.01 (95% CI = 0.0-0.10) resulting in an arterial injury posttest probability of 0%.
CONCLUSIONS
In PET patients, positive US may obviate CTA. In patients with a normal examination (no hard or soft signs) and a normal ABI, arterial injury can be ruled out. However, a normal ABI or negative US cannot independently exclude arterial injury. Due to high study heterogeneity, we cannot make recommendations when hard signs are present or absent or when ABI is abnormal. In these situations, one should use clinical judgment to determine the need for further observation, CTA or catheter angiography, or surgical exploration.
Topics: Adult; Ankle Brachial Index; Arteries; Emergency Service, Hospital; Extremities; Humans; Male; Physical Examination; Sensitivity and Specificity; Ultrasonography; Wounds, Penetrating
PubMed: 28493614
DOI: 10.1111/acem.13227 -
The Medical Journal of Malaysia May 2021A pseudoaneurysm, or false aneurysm, is a haematoma that is formed secondary to a leaking hole in an artery. This haematoma is contained by surrounding fascia. In...
A pseudoaneurysm, or false aneurysm, is a haematoma that is formed secondary to a leaking hole in an artery. This haematoma is contained by surrounding fascia. In contrast, a true aneurysm contains all three layers of vessel wall, namely intima. Pseudoaneurysms are scarce and can arise consequential of numerous iatrogenic influences, including but not limited to, blunt or penetrating trauma, orthopedic procedures like tibial nailing or ankle arthroscopy, and sports injury. A thorough history taking focusing on the recent history of trauma or instrumentation and clinical examination should raise the suspicion of a pseudoaneurysm. In doubtful cases, imaging modalities such as an ultrasound and doppler examination of the lower limb can be utilized to confirm the diagnosis. Our case was a 37-year-old gentleman presented with progressive swelling in the anterior aspect of his left leg for the past two weeks. The patient had a atypical presentation, with absence of classic signs of a pseudoaneurysm such as a pulsatile mass, absence distal pulses or a thrill or bruit. However, these injuries albeit rare can be sinister and prompt diagnosis is critical, so that pertinent treatment can be delivered. Our case highlights the importance of sonographic approaches for suspected vascular injuries.
Topics: Adult; Aneurysm, False; Hematoma; Humans; Leg; Male; Tibial Arteries; Wounds, Penetrating
PubMed: 34031347
DOI: No ID Found -
European Spine Journal : Official... Sep 2011Blunt traumatic vertebral injury (TVAI) is frequently associated with head and neck injury and is being detected with increasing frequency due to improved imaging of the... (Review)
Review
Blunt traumatic vertebral injury (TVAI) is frequently associated with head and neck injury and is being detected with increasing frequency due to improved imaging of the trauma patient. In a few cases, it can lead to potentially fatal posterior circulation ischaemia There is debate in the literature regarding whether TVAI should be actively screened for and, if so, how. Management of TVAI may be conservative, medical (antiplatelet agents or anticoagulation), endovascular or open surgery. We review the literature concerning the mechanisms and presentation of TVAI following blunt injury and the current screening recommendations. Management strategies proposed are based on the radiological grade and clinical severity of TVAI, where high-grade symptomatic injuries and high-grade injuries in patients where anticoagulation is contraindicated are treated endovascularly and asymptomatic or low-grade injuries are managed with anticoagulation where it is not contraindicated. Follow-up is via CT angiography to assess for resolution of the injury.
Topics: Anticoagulants; Humans; Radiography; Vascular System Injuries; Vertebral Artery; Wounds, Nonpenetrating
PubMed: 21674212
DOI: 10.1007/s00586-011-1862-y -
The Western Journal of Emergency... Dec 2015Penetrating injury to the forearm may cause an isolated radial or ulnar artery injury, or a complex injury involving other structures including veins, tendons and... (Review)
Review
INTRODUCTION
Penetrating injury to the forearm may cause an isolated radial or ulnar artery injury, or a complex injury involving other structures including veins, tendons and nerves. The management of forearm laceration with arterial injury involves both operative and nonoperative strategies. An evolution in management has emerged especially at urban trauma centers, where the multidisciplinary resource of trauma and hand subspecialties may invoke controversy pertaining to the optimal management of such injuries. The objective of this review was to provide an evidence-based, systematic, operative and nonoperative approach to the management of isolated and complex forearm lacerations. A comprehensive search of MedLine, Cochrane Library, Embase and the National Guideline Clearinghouse did not yield evidence-based management guidelines for forearm arterial laceration injury. No professional or societal consensus guidelines or best practice guidelines exist to our knowledge.
DISCUSSION
The optimal methods for achieving hemostasis are by a combination approach utilizing direct digital pressure, temporary tourniquet pressure, compressive dressings followed by wound closure. While surgical hemostasis may provide an expedited route for control of hemorrhage, this aggressive approach is often not needed (with a few exceptions) to achieve hemostasis for most forearm lacerations. Conservative methods mentioned above will attain the same result. Further, routine emergent or urgent operative exploration of forearm laceration injuries are not warranted and not cost-beneficial. It has been widely accepted with ample evidence in the literature that neither injury to forearm artery, nerve or tendon requires immediate surgical repair. Attention should be directed instead to control of bleeding, and perform a complete physical examination of the hand to document the presence or absence of other associated injuries. Critical ischemia will require expeditious surgical restoration of arterial perfusion. In a well-perfused hand, however, the presence of one intact artery is adequate to sustain viability without long-term functional disability, provided the palmar arch circulation is intact. Early consultation with a hand specialist should be pursued, and follow-up arrangement made for delayed primary repair in cases of complex injury.
CONCLUSION
Management in accordance with well-established clinical principles will maximize treatment efficacy and functional outcome while minimizing the cost of medical care.
Topics: Arteries; Forearm; Forearm Injuries; Humans; Lacerations; Ligation; Tourniquets; Trauma Centers
PubMed: 26759666
DOI: 10.5811/westjem.2015.10.28327 -
Journal of Ayub Medical College,... 2022Penetrating heart injuries are associated with higher mortality rates. Coronary lesions caused by penetrating trauma are considered even rarer and universally fatal. We...
Penetrating heart injuries are associated with higher mortality rates. Coronary lesions caused by penetrating trauma are considered even rarer and universally fatal. We present a case of a fortunate survivor who had complete transection of left anterior descending (LAD) artery with right ventricular (RV) tear after being stabbed by knife, arriving in emergency unit with massively bleeding chest wound. Complex cardiac trauma involving coronaries and cardiac chambers is a challenge to surgeons if patients miraculously reach the hospital alive. This patient had complete transection of LAD artery with penetration into RV cavity, he was successfully managed by timely and prompt surgical intervention by on call team. This case highlights the importance of team dynamics working in harmony during emergency situations, we stress upon conducting routine drills to train surgical residents, perfusionists and operation theatre staff.
Topics: Male; Humans; Wounds, Stab; Wounds, Penetrating; Thoracic Injuries; Heart Injuries; Coronary Vessels
PubMed: 36550672
DOI: 10.55519/JAMC-04-S4-10328