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Partial resuscitative endovascular balloon occlusion of the aorta (pREBOA) is a potential method to mitigate the ischemia observed in full REBOA (fREBOA). However, the effect of pREBOA on cerebral perfusion in the setting of raised intracranial pressure (rICP) is unknown. The aim was to evaluate the effects of no REBOA (nREBOA) vs pREBOA vs fREBOA on cerebral perfusion in a swine model of rICP and hemorrhagic shock.Anesthetized swine (n = 18) underwent instrumentation. Controlled hemorrhage was performed over 30 minutes. rICP was achieved using an intracranial Fogarty catheter inflated to achieve an ICP of 20 mmHg. Animals underwent intervention for 30 minutes, followed by resuscitation. The primary outcome was cerebral perfusion measured by ICP (millimeters of mercury), cerebral perfusion pressure (CPP; millimeters of mercury), and cerebral blood flow (CBF; milliliters per minute per 100 g) derived from CT perfusion. The secondary outcomes included hemodynamics and lactate (millimoles per liter).The peak ICP of pREBOA animals (22.7 ± 2.5) was significantly lower than nREBOA and fREBOA. pREBOA CPP was significantly higher compared with nREBOA and fREBOA during resuscitation. The pREBOA CBF was greater during intervention and resuscitation compared with nREBOA (p0.001). Systolic blood pressure was similar between pREBOA and fREBOA, and coronary perfusion was significantly greater in pREBOA. fREBOA had significantly higher lactate during the intervention (9.3 ± 1.3) and resuscitation (8.9 ± 3.5) compared with nREBOA and pREBOA.pREBOA produced greater cerebral perfusion, as demonstrated by more favorable CPP, CBF, and ICP values. fREBOA was associated with metabolic derangement and diminished pressure during resuscitation. pREBOA is superior to fREBOA in a swine model and should be considered over fREBOA for aortic occlusion.

Selective aortic arch perfusion (SAAP) is an endovascular technique that consists of aortic occlusion with perfusion of the coronary and cerebral circulation. It been shown to facilitate return of spontaneous circulation (ROSC) after exanguination cardiac arrest (ECA), but it is not known how long arrest may last before the myocardium can no longer be durably recovered. The aim of this study is to assess the myocardial tolerance to exsanguination cardiac arrest before successful ROSC with SAAP.Male adult swine (n = 24) were anesthetized, instrumented, and hemorrhaged to arrest. Animals were randomized into three groups: 5, 10, and 15 min of cardiac arrest before resuscitation with SAAP. Following ROSC, animals were observed for 60 min in a critical care environment. Primary outcomes were ROSC, and survival at 1-h post-ROSC.Shorter cardiac arrest time was associated with higher ROSC rate and better 1-h survival. ROSC was obtained for 100% (8/8) of the 5-min ECA group, 75% (6/8) of the 10-min group, 43% (3/7) of the 15-min group (P = 0.04). One-hour post-ROSC survival was 75%, 50%, and 14% in 5-, 10-, and 15-min groups, respectively (P = 0.02). One-hour survivors in the 5-min group required less norepinephrine (1.31 mg ± 0.83 mg) compared with 10-SAAP (0.76 mg ± 0.24 mg), P = 0.008.Whole blood SAAP can accomplish ROSC at high rates even after 10 min of unsupported cardiac arrest secondary to hemorrhage, with some viability beyond to 15 min. This is promising as a tool for ECA, but requires additional optimization and clinical trials.Animal Use Protocol, IACUC: 0919015.

This cohort study quantifies the yearly trends and outcomes of transcarotid artery revascularization vs transfemoral carotid artery stenting among high-risk patients from 2015 to 2021.

Introduction Upper extremity arterial injury is associated with significant morbidity and mortality for trauma patients, but there is a paucity of data to guide the clinician in the management of these injuries. The goals of this review were to characterize the demographics, presentation, clinical management, and outcomes, and to evaluate how time to intervention associates with outcomes in trauma patients with upper extremity vascular injuries. Methods The National Trauma Data Bank (NTDB) Research Data Set for the years 2007–2016 was queried in order to identify adult patients (age ≥ 18) with an upper extremity arterial injury. Patients with brachiocephalic, subclavian, axillary, or brachial artery injury using the 1998 and 2005 versions of the Abbreviated Injury Scale were included. Patients with non-survivable injuries to the brain, traumatic amputation, or other major arterial injuries to the torso or lower extremities were excluded. Results The data from 7908 patients with upper extremity arterial injuries was reviewed. Of those, 5407 (68.4%) underwent repair of the injured artery. The median Injury Severity Score (ISS) was 10 (IQR = 7–18), and 7.7% of patients had a severe ISS (≥ 25). Median time to repair was 120 min (IQR = 60–240 min). Management was open repair in 52.3%, endovascular repair in 7.3%, and combined open and endovascular repairs in 8.8%; amputation occurred in 1.8% and non-operative management was used in 31.6% of patients. Blunt mechanism of injury, crush injury, concomitant fractures/dislocations, and nerve injuries were associated with amputation, whereas simultaneous venous injury was not. There was a significant decrease in the rate of amputation when patients undergoing surgical revascularization did so within 90 min of injury (P = 0.007). Conclusion Injuries to arteries of the upper extremity are managed with open repair, endovascular repair, and, rarely, amputation. Expeditious transport to the operating room for revascularization is the key for limb salvage.

The ideal conduit for traumatic arterial repair is controversial. Autologous vein was compared with synthetic interposition grafts in the acute setting. The primary outcome was in-hospital reoperation or endovascular intervention.The American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment registry from November 2013 to January 2019 was queried for arterial injuries requiring interposition vein or graft repair. Patients with no recorded Injury Severity Score were excluded, and multiple imputation was used for other missing data. Patients treated with synthetic grafts (SGs) were propensity matched to patients with vein grafts (VGs) to account for preoperative differences.Four hundred sixty from 19 institutions were identified, with 402 undergoing VG and 58 SG. In the SG group, 45 were PTFE grafts, 5 were Dacron, and 8 had other conduits. The SG group was more severely injured at admission with more gunshot wounds and higher mean Injury Severity Score, lactate, and first-24-hour transfusion requirement. In addition, the SG cohort had significantly lower admission systolic blood pressure, pH, and hemoglobin. After propensity matching, 51 patients with SG were matched with 87 patients with VG. There were no differences in demographics, clinical parameters, or diagnostic evaluation techniques postmatch. The need for reoperation or endovascular intervention between the matched groups was equivalent (18%; p = 0.8). There was no difference in any secondary outcome including thrombosis, stenosis, pseudoaneurysm, infection, or embolic event, and hospital and intensive care unit length of stay were the same.American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment registry data demonstrate that SGs are used in more critically ill patients. After controlling for relevant clinical factors and propensity matching, there is no in-hospital difference in rate of reoperation or endovascular intervention, or any secondary outcome between VG and SG.Prognostic and Epidemiolgic, Level III.

Introduction Trauma patients have diverse resource needs due to variable mechanisms and injury patterns. The aim of this study was to build a tool that uses only data available at time of admission to predict prolonged hospital length of stay (LOS). Methods Data was collected from the trauma registry at an urban level one adult trauma center and included patients from 1/1/2014 to 3/31/2019. Trauma patients with one or fewer days LOS were excluded. Single layer and deep artificial neural networks were trained to identify patients in the top quartile of LOS and optimized on area under the receiver operator characteristic curve (AUROC). The predictive performance of the model was assessed on a separate test set using binary classification measures of accuracy, precision, and error. Results 2953 admitted trauma patients with more than one-day LOS were included in this study. They were 70% male, 60% white, and averaged 47 years-old (SD: 21). 28% were penetrating trauma. Median length of stay was 5 days (IQR 3-9). For prediction of prolonged LOS, the deep neural network achieved an AUROC of 0.80 (95% CI: 0.786-0.814) specificity was 0.95, sensitivity was 0.32, with an overall accuracy of 0.79. Conclusion Machine learning can predict, with excellent specificity, trauma patients who will have prolonged length of stay with only physiologic and demographic data available at the time of admission. These patients may benefit from additional resources with respect to disposition planning at the time of admission.

BACKGROUND Associated injuries are thought to increase mortality in patients with severe abdominopelvic trauma. This study aimed to identify clinical factors contributing to increased mortality in patients with severe abdominopelvic trauma, with the hypothesis that a greater number of concomitant injuries would result in increased mortality. METHODS This was a retrospective review of the Trauma Quality Improvement Program (TQIP) database of patients ≥ 18 years with severe abdominopelvic trauma defined as having an abdominal Abbreviated Injury Score (AIS) ≥ 3 with pelvic fractures and/or iliac vessel injury (2015-2017). Primary outcome was in-hospital mortality based on concomitant body region injuries. Secondary outcomes included mortality at 6 h, 6 to 24 h, and after 24 h based on concomitant injuries, procedures performed, and transfusion requirements. RESULTS A total of 185,257 patients were included in this study. Survivors had more severely injured body regions than non-survivors (4 vs. 3, P

ImportanceA transcarotid artery revascularization (TCAR) device was approved by the US Food and Drug Administration in 2015 for carotid revascularization in patients at high risk for stroke, cranial nerve injury, or major cardiac event. It is unclear how the introduction of TCAR has changed the use of carotid endarterectomy (CEA) and transfemoral carotid artery stenting (TFCAS).ObjectiveTo quantify the temporal changes in the operative approach to carotid revascularization (CEA vs TFCAS vs TCAR), and to identify patient and disease characteristics commonly associated with each approach.Design, Setting, and ParticipantsThis retrospective cohort study obtained data from the Vascular Quality Initiative database from January 1, 2015, to December 31, 2019. Patients with carotid artery stenosis who underwent CEA, TFCAS, or TCAR were included. Data were analyzed from January to April 2022.ExposuresMonth and year of surgery as well as patient risk status.Main Outcomes and MeasuresNumber and proportion of carotid revascularization procedures by operative approach.ResultsA total of 108 676 patients (mean [SD] age 56.6 [12.5] years; 66 684 men [61.4%]) were included in the analysis. The most common operative approach overall was CEA (n = 81 508 [75.0%]), followed by TFCAS (n = 15 578 [14.3%]) and TCAR (n = 11 590 [10.7%]). The number of procedures increased over the study period (16 754 in 2015 vs 27 269 in 2019; P P P Conclusions and RelevanceResults of this study indicate that TCAR has become the dominant carotid revascularization approach, surpassing TFCAS and CEA in patients at high risk for stroke, cranial nerve injury, or cardiovascular events. Patient high-risk status was the main characteristic associated with a stenting approach, highlighting the perceived importance of carotid stenting therapies in this patient population.

Acute arterial occlusion of the lower extremity is a time-dependent emergency that requires prompt revascularization. Lower extremity extracorporeal distal revascularization (LEEDR) is a technique that can be initiated bedside when definitive therapy is delayed. The aim of this study is to evaluate this technique in a swine model of prolonged extremity ischemia.Anesthetized swine underwent right femoral and left posterior tibial artery cannulation, left iliac venous flow monitoring (mL/min), and continuous left anterior compartment pressure (CP) monitoring (mm Hg). The iliac artery was clamped for 6 hr. LEEDR animals underwent 5 hr of extracorporeal femoral-to-tibial blood flow at 150 mL/min; controls had no intervention. At 6 hr, LEEDR was discontinued, iliac flow restored, and anterior CP monitored for 3 hr.Baseline characteristics were similar across both the groups. Iliac clamping saw an expected fall in iliac venous flow (258 ± 30 to 82 ± 19; P 0.001). LEEDR resulted in a rise in iliac venous flow (82 ± 20 to 181 ± 16; P 0.001); control arm flow remained reduced (71 ± 8; P 0.001). Once inflow was restored, venous flow returned to baseline. Revascularization provoked a higher peak CP in the control arm versus in the LEEDR group (25 ± 5 vs. 6 ± 1; P = 0.02).An extracorporeal circuit can temporarily revascularize an extremity in a swine model of prolonged ischemia, mitigating reperfusion injury and maintaining normal CPs. This concept should undergo further evaluation as a bedside tool to mitigate extremity ischemia prior to definitive revascularization.

Noncompressible hemorrhage, such as pelvic hemorrhage, is associated with a high mortality rate and is a potentially preventable cause of death. Blood transfusion is a critical part of resuscitation, however, the availability or storage of blood products in austere and rural settings can impede or delay necessary transfusion. Similarly, large animal laboratories may also have limited resources, such as no banked animal blood. To minimize the need for donor blood products, blood recovery and autotransfusion can be performed using an intra-operative cell salvage machine. While this technique has proven to be beneficial, it is expensive, requires electricity, and can delay the time of transfusion. Recently, a handheld autotransfusion device was created for rural, remote, or low-resource facilities to return shed blood back to a patient or animal undergoing surgery quickly. To determine the resuscitative feasibility of the device, we sought to develop a swine model of open intraperitoneal pelvic hemorrhage, which is a common clinical scenario in low resource settings where cesarean section is one of the most common operations. The aim of this study is to use a model of pelvic hemorrhage to compare resuscitation strategies encountered in austere environments:Strategy 1 (control arm): a crystalloid-based resuscitation.Strategy 2 (therapeutic arm): salvaged, filtered blood recovered by a novel handheld device.Primary outcome: · Red blood cell mass (hematocrit) at four hours following resuscitation.Secondary outcomes: · Hematologic: complete blood count (WBC, RBC, Hb, Hct, platelet count), free Hb, blood smear, blood culture, and potassium. · Coagulation: thromboelastography (TEG), INR, PT, aPTT, ACT. · Hemodynamic measures: mean arterial pressure and heart rate trends. · Device: time to evacuate blood and time to re-transfusion.

Local trauma care and regional trauma systems are data-rich environments that are amenable to machine learning, artificial intelligence, and big-data analysis mechanisms to improve timely access to care, to measure outcomes, and to improve quality of care. Pilot work has been done to demonstrate that these methods are useful to predict patient flow at individual centers, so that staffing models can be adapted to match workflow. Artificial intelligence has also been proven useful in the development of regional trauma systems as a tool to determine the optimal location of a new trauma center based on trauma-patient geospatial injury data and to minimize response times across the trauma network. Although the utility of artificial intelligence is apparent and proven in small pilot studies, its operationalization across the broader trauma system and trauma surgery space has been slow because of cost, stakeholder buy-in, and lack of expertise or knowledge of its utility. Nevertheless, as new trauma centers or systems are developed, or existing centers are retooled, machine learning and sophisticated analytics are likely to be important components to help facilitate decision-making in a wide range of areas, from determining bedside nursing and provider ratios to determining where to locate new trauma centers or emergency medical services teams.

There have been no data to support the use of tibial interventions in the treatment of claudication to date. We aimed to characterize the practice patterns surrounding tibial peripheral vascular interventions (PVI) in patients with claudication in the United States.Using 100% Medicare fee-for-service claims from 2017 to 2019, we conducted a retrospective analysis of all patients undergoing an index PVI for claudication. Patients who had any previous PVI, acute limb ischemia, or chronic limb-threatening ischemia in the preceding 12 months were excluded. The primary outcome was the receipt or delivery of tibial revascularization during index PVI for claudication, defined as tibial PVI with or without concomitant femoropopliteal PVI. Univariable comparisons and a multivariable hierarchical logistic regression were used to assess patient and physician characteristics associated with the use of tibial PVI for claudication.Of 59,930 Medicare patients who underwent index PVI for claudication between 2017 and 2019, 16,594 (27.7%) received a tibial PVI (38.5% isolated tibial PVI and 61.5% tibial PVI with concomitant femoropopliteal PVI). Of 1,542 physicians included in the analysis, the median physician-level tibial PVI rate was 20.0% (IQR 9.1%-37.5%). Hierarchical logistic regression suggested that patient-level characteristics associated with tibial PVI for claudication included male sex (adjusted odds ratio [aOR] 1.23), increasing age (aOR1.30-1.96), Black race (aOR 1.47), Hispanic ethnicity (aOR 1.86), diabetes (aOR 1.36), no history of hypertension (aOR 1.12), and never-smoking (aOR 1.64; all, P0.05). Physician-level characteristics associated with tibial PVI for claudication included early-career status (aOR 2.97), practice location in the West (aOR 1.75), high-volume PVI practice (aOR 1.87), majority practice in an ASC/OBL setting (aOR 2.37), and physician specialty; vascular surgeons had significantly lower odds of performing tibial PVI compared to radiologists (aOR 2.98) and cardiologists (aOR 1.67; all, P0.05). Average Medicare reimbursement per patient was dramatically higher for physicians performing high rates of tibial PVI (quartile 4 vs. quartile 1-3: $12,023.96 vs. $692.31 per patient, P0.001).Tibial PVI for claudication are performed more commonly by non-vascular surgeons, in high-volume practices, and in high-reimbursement settings. This reveals a critical need to reevaluate the indications, education, and reimbursement policies surrounding these procedures.

Traumatic injuries to the pelvis, extremities, or extremity vessels have improved outcomes when there is early restoration of perfusion (Laverty et al, Hancock et al). An ex-vivo shunting device, such as the Lower Extremity Extracorporeal Distal Revascularization (LEEDR) system, offers a potential solution to perfuse an ischemic limb in situations where definitive repair is not available, or transfer or delay is inevitable. A large animal model is required to optimize the surgical technique and management strategies. Acknowledging the morphological differences between bipeds and quadrupeds (Edwards et al), the aim of this study is to use a model of prolonged extremity ischemia to determine whether a LEEDR system can be used to mitigate ischemia by reducing compartment pressures and the need for fasciotomies following reperfusion. We sought to develop a method where an extracorporeal shunt from the contralateral common femoral artery to the ipsilateral tibial artery in the setting of limb ischemia to provide distal perfusion. Following a period of controlled ischemia, we developed a model with a low resistance circuit and 150 mL/min pump to perfuse an ischemic extremity at a distal point utilizing the contralateral proximal femoral vessel as outflow.

Targeted temperature management plays an important role in the treatment of myriad critical illnesses. Invasive therapies such as ECMO and cooled intravenous fluid are available but are invasive and not without risk. Noninvasive therapies are also available such as ice packs and cooling blankets but like the invasive options these do not provide isolated brain cooling. This off-target cooling likely has hemodynamic, coagulopathic and other effects which may not be desired. Non-invasive, quick-onset and portable options for control of brain temperature remain lacking. Here, we are testing a non-invasive intra-nasal cooling system which provides cooled air to facilitate brain cooling. The goal of this study is to assess the efficacy and short- and medium-term safety of a novel, intranasal high flow cooled air device on a large animal model system.

Background: Intraoperative computed tomography (CT) imaging with endovascular catheter delivery of intra-arterial (IA) contrast could potentially provide higher signal attenuation in directed anatomic locations with lower contrast volumes. We compared image quality and attenuation timing of IA versus IV contrast protocols for abdominal imaging. Methods: Five anesthetized swine had internal jugular access and ascending aortic pigtails placed percutaneously via the brachial artery. The IV contrast protocol utilized 100 mL of iodinated contrast at 5 mL/sec over 20/sec. The IA protocol delivered 50 mL at 5 mL/sec over 10/sec. A 16-slice CT scanner with a 10 mm detector acquired static serial images at 1 image/second for 45 secs. Region-of-interest markers were used to select the aorta and portal vein to capture arterial and venous attenuation via Hounsfield Units (HU) per second. Attenuation curves were assessed using a Pearson’s correlation. Adequate attenuation was defined as >100 HU a priori and image quality assessed using Contrast-to-Noise Ratio (CNR). Results: Both contrast protocols achieved adequate image attenuation with an aortic peak of 665 ± 226 (Mean HU ± SD) for IA and 414 ± 141 for IV. IA contrast achieved faster peak aortic attenuation compared to IV contrast [8 vs 20 sec; p2 >0.94; p Conclusion: IA contrast achieves adequate opacification and a superior CNR compared to IV contrast, while using a smaller volume for intraoperative directed imaging. The incorporation of intraoperative CT with IA contrast could radically change imaging protocols for endovascular aortic repair.

Polyarteritis nodosa (PAN) is a rare vasculitis that can cause peripheral ischemia. We present the case of a 49-year-old man who developed PAN causing toe gangrene and severe rest pain in one foot and claudication of the contralateral foot. He was treated with immunosuppression and underwent popliteal-plantar artery bypass with resolution of rest pain and subsequent amputation of his mummified toe. Despite remission of PAN, his contralateral foot claudication was lifestyle limiting; thus, 5 years later he underwent contralateral popliteal-plantar bypass with resolution of claudication. This case demonstrates the anatomically symmetric presentation of PAN induced ischemia with successful open revascularization after resolution of inflammatory markers with systemic therapy.

Objective Thoracic Endovascular Aortic Repair (TEVAR) is well established in humans. Despite widespread use, additional research questions related to thoracic aortic stenting and endovascular innovation require large animal models. Translating human TEVAR devices and techniques into animal models, however, is a challenge even for experienced endovascular surgeons looking to develop a large animal TEVAR model. This article describes swine-specific strategies to deploy human TEVAR stent grafts, delineate how to select, size, prepare, and re-use human stents and deployment systems in swine, and how to translate human imaging modalities to large animal TEVAR. Methods We describe a selection of related TEVAR models and techniques in Yorkshire swine to support scientific inquiry. This includes an animal husbandry and pre-operative preparation and planning program. All imaged specimens in this paper are castrated male Yorkshire swine in the 60–80 kg range and underwent TEVAR with the Medtronic Navion stent and deployment system. Results To study human aortic stent grafts in swine, the animals generally must be at least 50 kgs to guarantee a 2 cm internal aortic diameter at the left subclavian, and for the iliac arteries to accommodate the human deployment system. Swine will have longer torsos and shorter iliofemoral segments than a human of the same weight which can make human deployment systems too short to reach the left subclavian from the femoral arteries in larger animals. We provide techniques to overcome this, including open iliac access or upside-down carotid TEVAR, which may be particularly useful if the scientific data would be confounded by iliofemoral access. Unlike humans that present clinically with axial imaging, swine will generally not have preoperative imaging, and many translational research laboratories do not have access to inexpensive preoperative CT, or any intraoperative CT scanning, which we are fortunate to have. We describe, therefore, several strategies for imaging in this setting including TEVAR via C-arm fluoroscopy and with or without in-laboratory CT scanning. Due to the low-resource setting of most large animal laboratories, as compared to a human hybrid room, we also describe several techniques to reduce cost and reuse materials, including the stent grafts, which at the end of non-survival experiments can be recovered during necropsy, cleaned, reinserted into the deployment device and reused on additional animals. Conclusions This article describes a collection of related techniques and tips to translate human TEVAR imaging, sizing/selection, deployment, and anatomy to swine research. Using this framework alone, an experienced human vascular or endovascular surgeon may develop a complete aortic stenting animal model with strategies for scientific data acquisition.

Current professional guidelines recommend best medical therapy (BMT) with statin agents and antiplatelet therapy for primary and secondary stroke prevention in patients with carotid artery stenosis. We aimed to assess the association of patient sex with preoperative BMT in patients undergoing carotid revascularization.We performed a retrospective review of Vascular Quality Initiative patients who underwent carotid endarterectomy or carotid artery stenting between January 2003 and February 2022. Multivariable logistic regression models were used to assess the association of patient sex with preoperative BMT after adjusting for sociodemographic, comorbidity, and disease severity characteristics. In-hospital outcomes were assessed by sex and preoperative BMT status.Of 214,008 patients who underwent carotid revascularization, 38.7% (n = 82,855) were female and 61.3% (n = 131,153) were male. Overall, 77.2% (n = 63,922) of females were on preoperative BMT, compared with 80.4% (n = 105,375) of males (P .001). After adjusting for baseline differences, females had 11% lower odds of being on BMT compared with males (adjusted odds ratio, 0.89; 95% confidence interval, 0.86-0.91). Postoperatively, females had 18% lower odds of being prescribed BMT than males (adjusted odds ratio, 0.82; 95% confidence interval, 0.79-0.84). In-hospital stroke (1.20% vs 1.51%), death (0.37% vs 0.66%), and stroke/death (1.46% vs 1.98%) were all significantly lower for patients on BMT (all P .001).There is a significant discrepancy in the proportion of females versus males receiving preoperative BMT for stroke prevention before carotid artery revascularization. In-hospital outcomes are worse in patients without BMT, highlighting the importance of raising awareness and implementing targeted interventions to improve preoperative adherence to stroke prevention guidelines.

Intraoperative computed tomography (CT) imaging with endovascular delivery of intra-arterial (IA) contrast could potentially provide higher attenuation with lower contrast volumes than intravenous (IV) administration. We aimed to compare IA and IV contrast use for organ-specific CT abdominal imaging. Five anesthetized swine had external jugular and brachial artery access with ascending aortic pigtail placement. An IV protocol was 100 mL at 5 mL/sec over 20 sec vs 50 mL of IA contrast at 5 mL/sec over 10 sec. Region-of-interest markers were applied to anatomical regions to measure attenuation (HU) over time. IA and IV contrast protocols achieved adequate aortic opacification (IA, 455 ± 289 vs IV, 450 ± 114 HU). The IA contrast aortic attenuation curve reached peak attenuation compared with IV contrast (IA, 8 vs 23 sec; P < .001). Time to peak attenuation was similar between IA and IV contrast in the portal vein (IA, 38 vs IV, 42 sec, P = .25). IA administration achieved a superior contrast-to-noise ratio (CNR) in less time compared with IV (R2 = .94; P < .001). IA contrast achieved adequate opacification with less bolus broadening and a superior CNR compared with IV contrast while using a smaller contrast volume for directed organ-directed imaging.

We previously demonstrated that everolimus drug-eluting stents (eDES) have reasonable short-term patency for the treatment of infrainguinal bypass stenoses. The aim of this study is to compare mid-term outcomes of eDES, plain balloon angioplasty (PTA), percutaneous cutting balloon (PCB), and drug-coated balloon (DCB) interventions for failing infrainguinal bypasses.We conducted a retrospective review of patients with infrainguinal bypass stenoses treated by endovascular intervention (August 2010-August 2021). The primary outcome was primary patency (PP). Secondary outcomes were primary-assisted patency (PAP), secondary patency (SP), limb salvage (LS), and mortality. Outcomes were compared by treatment using Kaplan-Meier curves with log-rank tests and Cox proportional hazards models adjusting for baseline differences between groups.Seventy-two consecutive patients with 152 discrete infrainguinal bypass graft stenoses were identified. Mean age was 65.1 ± 10.6 years, 55.6% were male, and 48.6% were Black. In total, 81.9% of patients were originally treated for chronic limb-threatening ischemia, and 57.2% of distal anastomoses were to tibial or pedal targets. Of 152 lesions, 44.1% (n = 67) were treated with PTA, 17.8% (n = 27) with PCB, 20.4% (n = 31) with DCB, and 17.8% (n = 27) with eDES. Median follow-up was 28.5 months (interquartile range 11.5-51.9). There was no difference in bypass configuration, conduit choice, or stenosis location (proximal anastomosis, mid-bypass, distal anastomosis) between groups. At 24 months postintervention, PP was significantly better for eDES (72.9%, 95% confidence interval [CI] 49.8-85.6), followed by PCB (55.9%, 95% CI 34.2-72.9), PTA (34.4%, 95% CI 21.7-47.4), and DCB (33.6%, 95% CI 14.5-53.9) (P = 0.03). PAP, LS, and mortality did not significantly differ between modalities (P 0.05). After risk adjustment, eDES was associated with the lowest risk of PP loss (hazard ratio versus PTA 0.15, 95% CI 0.05-0.47).eDES is associated with superior 24-month patency rates compared to other endovascular technologies, and should be considered a primary therapy modality for the treatment of infrainguinal bypass graft stenoses.

Introduction The use of antiplatelet (AP) and anticoagulation (AC) therapy after autogenous vein repair of traumatic arterial injury is controversial. The hypothesis in this study was that there is no difference in early postoperative outcomes regardless of whether AC, AP, both, or neither are used. Methods The American Association for the Surgery of Trauma (AAST) PROspective Observational Vascular Injury Treatment (PROOVIT) registry was queried from November, 2013, to January, 2019, for arterial injuries repaired with a vein graft. Demographics and injury characteristics were compared. Need for in-hospital reoperation was the primary outcome in this four-arm study, assessed with two ordinal logistic regression models (1. no therapy vs. AC only vs. AC and AP; 2. no therapy vs. AP only vs. AC and AP). Results 373 patients (52 no therapy, 88 AP only, 77 AC only, 156 both) from 19 centers with recorded Injury Severity Scores (ISS) were identified. Patients who received no therapy were younger than those who received AP (27.0 vs. 34.2, p = 0.02), had higher transfusion requirement ( p < 0.01 between all groups) and a different distribution of anatomic injury ( p < 0.01). After controlling for age, sex, ISS, platelet count, hemoglobin, pH, lactate, INR, transfusion requirement and anatomic location, there was no association with postoperative medical therapy and in-hospital operative reintervention, or any secondary outcome, including thrombosis ( p = 0.67, p = 0.22). Conclusions Neither AC nor AP alone, nor in combination, impact complication rate after arterial repair with autologous vein. These patients can be safely treated with or without antithrombotics, recognizing that this study did not demonstrate a beneficial effect.

Hemorrhage is among the leading causes of preventable deaths in trauma. Further traumatic brain injury (TBI) often present in a polytrauma patient, and is known to worsen outcomes when present with non compressible torso hemorrhage (NCTH). Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been developed as a means of hemorrhage control and afterload increase during a state of hemorrhagic shock, but its use in patients with both hemorrhagic shock and concomitant TBI is controversial, as the potential for ischemia reperfusion injury and acute hypertension may cause intracranial lesion progression. To date, there is limited data on how REBOA alters hemodynamics in a model of hemorrhagic shock and brain injury resulting in raised intracranial pressure. The goal of the current study is to define how full REBOA and partial REBOA alter systemic and cerebral hemodynamics in a porcine model of TBI with raised ICP with concomitant hemorrhagic shock. This will be examined throughout the intervention and for 3 hours of resuscitation. It will be evaluated with hemodynamic, laboratory, and radiographic assessments.