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OBJECTIVE Iatrogenic vascular injuries (IaVI's) appear to be increasing, with disparate prevalence across gender, race and ethnicity. We aim to assess the risk of IaVI's across these characteristics. METHODS Using the Nationwide Inpatient Sample for the years 2008-2015, we identified rates of IaVI's among the top ten most frequently performed inpatient procedures in the United States. Joint point regression was employed to examine the trends in the rates of IaVI's. We also calculated the adjusted odds ratios for IaVI's using survey logistic regression. RESULTS During the eight-year study period, a total of 29,877,180 procedures were performed (33.6% hip replacement, 14% knee arthroplasty, 11.2% cholecystectomy, 10.3% spinal fusion, 8.9% lysis of adhesions, 8% colorectal resection, 7.9% partial bone excision, 5% appendectomy, 0.6% percutaneous coronary angioplasty, 0.6% laminectomy). A total of 194,031 (0.65%) IaVI's were associated with these procedures. The incidence of IaVI's increased over time with an average annual percentage change (AAPC) of 4.2% (95% CI: 3.1, 5.4; P < 0.01). More females (105,747; 54.5%) than males (88,284; 45.5%) suffered IaVI's during their hospital admission (p < 0.01). Patients 70 years of age and older had the highest incidence of IaVI's (12,244,082; 34.3%; p =

Background Women have been historically under-represented in vascular surgery and cardiovascular medicine trials. The rate and change in representation of women in trials of common vascular diseases over the last decade is not understood completely. Methods We used publicly available data from ClinicalTrials.gov to evaluate trials pertaining to carotid artery stenosis (CAS), peripheral arterial disease (PAD), thoracic and abdominal aortic aneurysms (TAA and AAA), and type B aortic dissections (TBAD) from 2008 to the present. We evaluated representation of women in these trials based on the participation-to-prevalence ratios (PPR), which are calculated by dividing the percentage of women among trial participants by the percentage of women in the disease population. Values of 0.8 to 1.2 reflect similar representation. Results The sex distribution was reported in all 97 trials, including 11 CAS trials, 68 PAD trials, 16 TAA/AAA trials, and 2 TBAD trials. The total number of participants in these trials was 41,622 and the median number of participants per trial was 150.5 (interquartile range [IQR], 50-252). The percentage of women in the disease population was 51.9% for CAS, 53.1% for PAD, 34.1% for TAA/AAA, and 30.9% for TBAD. Industry sources funded 76 of the trials (77.6%), and the Veterans Affairs Administration (n = 4 [4.1%]), unspecified university (n = 7 [7.1%]), and extramural sources (n = 11 [11.2%]) funded the remainder of the trials. The overall median PPR for all four diseases was 0.65 (IQR, 0.51-0.80). Women were under-represented for all four conditions studied (CAS, 0.73 [IQR, 0.62-0.96]; PAD, 0.65 [IQR, 0.53-0.77]; TAA/AAA, 0.59 [IQR, 0.38-1.20]; and TBAD, 0.74 [IQR, 0.65-0.84]). There was no significant difference in PPR among the diseases (P = .88). From 2008 to the present, there was no significant change in PPR values over time overall (r2 = 0.002; P = .70). When examined individually, PPR did not change significantly over time for any of the diseases studied (for each, r2 .45). The PPR did not vary significantly over time for any of the funding sources (for each, r2 .08). There was appropriate representation (PPR of 0.8-1.2) in a minority of trials for each disease except TBAD (CAS, 27.3%; PAD, 15.9%; TAA/AAA, 18.8%; and TBAD, 50%). Trials that were primarily funded from university sources had the highest median PPR (1.04; IQR, 0.21-1.27), followed by industry-funded (0.67; IQR, 0.54-0.81), and extramurally funded (0.60; IQR, 0.34-0.73). Studies funded by Veterans Affairs had the lowest PPR (0.02; IQR, 0.00-0.11; P = .004). Conclusions Participation of women in US trials of common vascular diseases remains low and has not improved since 2008. Therefore, the generalizability of recent trial results to women with these vascular diseases remains unknown. An improved understanding of the underlying root causes for poor female trial participation, advocacy, and education are required to improve the generalizability of trial results for female vascular patients.

Background Traditional assessment (e.g., checklists, videotaping) for surgical proficiency may lead to subjectivity and does not predict performance in the clinical setting. Hand motion analysis is evolving as an objective tool for grading technical dexterity; however, most devices accompany with technical limitations or discomfort. We purpose the use of flexible wearable sensors to evaluate the kinematics of surgical proficiency. Methods Surgeons were recruited and performed a vascular anastomosis task in a single institution. A modified objective structured assessment of technical skills (mOSATS) was used for technical qualification. Flexible wearable sensors (BioStamp RCTM, mc10 Inc., Lexington, MA) were placed on the dorsum of the dominant hand (DH) and nondominant hand (nDH) to measure kinematic parameters: path length (Tpath), mean (Vmean) and peak (Vpeak) velocity, number of hand movements (Nmove), ratio of DH to nDH movements (rMov), and time of task (tTask) and further compared with the mOSATS score. Results Participants were categorized as experts (n = 12) and novices (n = 8) based on a cutoff mean mOSATS score. Significant differences for tTask (P = 0.02), rMov (P = 0.07), DH Tpath (P = 0.04), Vmean (P = 0.07), Vpeak (P = 0.04), and nDH Nmove (P = 0.02) were in favor of the experts. Overall, mOSATS had significant correlation with tTask (r = −0.69, P = 0.001), Nmove of DH (r = −0.44, P = 0.047) and nDH (r = −0.66, P = 0.001), and rMov (r = 0.52, P = 0.017). Conclusions Hand motion analysis evaluated by flexible wearable sensors is feasible and informative. Experts utilize coordinated two-handed motion, whereas novices perform one-handed tasks in a hastily jerky manner. These tendencies create opportunity for improvement in surgical proficiency among trainees.

BACKGROUND Rational development of technology for rapid control of noncompressible torso hemorrhage (NCTH) requires detailed understanding of what is bleeding. Our objectives were to describe the anatomic location of truncal bleeding in patients presenting with NCTH and compare endovascular (ENDO) management versus open (OPEN) management. METHODS This is a retrospective study of adult trauma patients with NCTH admitted to four urban Level I trauma centers in the Houston and San Antonio metropolitan areas in 2008 to 2012. Inclusion criteria include named axial torso vessel disruption, Abbreviated Injury Scale chest or abdomen score of 3 or higher with shock (base excess

Objective Effective diabetic foot ulcer (DFU) care has been stymied by a lack of input from patients and caregivers, reducing treatment adherence and overall quality of care. Our objectives were to capture the patient and caregiver perspectives on experiencing a DFU and to improve prioritization of patient-centered outcomes. Methods A DFU-related stakeholder group was formed at an urban tertiary care center. Seven group meetings were held across 4 months, each lasting ∼1 hour. The meeting facilitator used semistructured questions to guide each discussion. The topics assessed the challenges of the current DFU care system and identified the outcomes most important to stakeholders. The meetings were audio recorded and transcribed. Directed and conventional content analyses were used to identify key themes. Results Six patients with diabetes (five with an active DFU), 3 family caregivers, and 1 Wound Clinic staff member participated in the stakeholder group meetings. The mean patient age was 61 years, four (67%) were women, five (83%) were either African American or Hispanic, and the mean hemoglobin A1c was 8.3%. Of the five patients with a DFU, three had previously required lower extremity endovascular treatment and four had undergone at least one minor foot amputation. Overall, stakeholders described how poor communication between medical personnel and patients made the DFU experience difficult. They felt overwhelmed by the complexity of DFU care and were persistently frustrated by inconsistent medical recommendations. Limited resources further exacerbated their frustrations and barriers to care. To improve DFU management, the stakeholders suggested a centralized healthcare delivery pathway with timely access to a coordinated, multidisciplinary DFU team. The clinical outcomes most valued by stakeholders were (1) avoiding amputation and (2) maintaining or improving health-related quality of life, which included independent mobility, pain control, and mental health. From these themes, we developed a conceptual model to inform DFU care pathways. Conclusions Current DFU management lacks adequate care coordination. Multidisciplinary approaches tailored to the self-identified needs of patients and caregivers could improve adherence. Future DFU-related comparative effectiveness studies will benefit from direct stakeholder engagement and are required to evaluate the efficacy of incorporating patient-centered goals into the design of a multidisciplinary DFU care delivery system.

Endovascular management of complex aortoiliac occlusive disease (AIOD) has been described as a viable alternative to open surgical reconstruction. To date, few studies have directly compared the 2 techniques. We therefore, evaluated short and mid- term outcomes of open and endovascular therapy in TASC II D AIOD patients.TASC II D patients undergoing treatment between January 2009 and December 2016 were retrospectively reviewed. Patient demographics, clinical data, and outcomes (complications [technical and systemic] and graft patency) were collected. The primary outcome of this study was primary graft patency. Patients were compared according to treatment group (open versus endovascular). Kaplan-Meier curves were used to analyze follow up results.A total of 75 consecutive patients (open: 30; endovascular: 45) were included in this analysis. In the endovascular group, 25 (55.6%) patients were managed using a hybrid approach with 100% technical success. Critical limb ischemia was the indication for intervention in 16.0% of this cohort (open, 13.3% vs. endovascular, 17.8%, P = 0.397). Overall, there were no significant differences in gender (male: open, 50.0% vs. endovascular, 55.6%, P = 0.637) or age (54.5 ± 5.9 years vs. 57.0 ± 8.7 years, P = 0.171). No in hospital deaths occurred in this cohort. The overall complication rate was significantly higher in the open group (43.3% vs. 17.8%, OR 3.5, 95% CI [1.2-10.1], P = 0.016) with peri-operative systemic complications being more likely in the open cohort (40.0% vs. 6.7%, OR 9.3, 95% CI [2.3-37.3], P 0.001) while technical complications did not differ between the 2 groups (6.7% vs. 11.1%, OR 0.6, 95% CI [0.1-3.1], P = 0.517). Follow up data was available for 68 patients (90.7%), for a mean of 21.3 ± 17.1 months (range: 1-72 months). Re-intervention rates were significantly higher in the endovascular group (3.3% vs. 20.0%, OR 7.2, 95% CI [1.1-14.3], P = 0.038). The overall primary patency at 2 years was significantly higher in the open group (96.7% vs. 80.0%, OR 7.2, 95% CI [1.2-60.5], P = 0.038). Cox regression analysis revealed separation of the primary outcome for open therapy relative to endovascular repair (log rank, P = 0.320).In this comparison of open and endovascular therapy for complex AIOD, endovascular therapy was associated with high initial technical success and fewer in-hospital systemic complications but also high re-intervention rates when compared to open repair. Further prospective studies aimed at reduction of complications, optimization of patency, and patient selection for such procedures is warranted.

Mesenteric ischemia can be difficult to diagnose without a high degree of suspicion because it presents in a variety of ways. Visceral vascular collaterals between the fore- and midgut often provide protection against ischemia; however, the presence of anatomic variations, such as celiomesenteric trunk, can undermine the expected redundancy. Misdiagnosis can result in prolonged suffering or death, as evidenced in 2 of our patients with celiomesenteric trunk. The first patient with chronic mesenteric ischemia was diagnosed in the clinic and underwent successful surgical correction; the other had overwhelming, acute mesenteric ischemia, which resulted in death. Our cases show that successful diagnosis and management of mesenteric ischemia require astute interpretation of radiologic images.

Traumatic injuries to peripheral arterial vessels are increasingly managed with endovascular techniques. Early small series have suggested that endovascular therapy is feasible and decreases operative blood loss, but these data are limited. The purpose of this study was to evaluate the feasibility and outcomes of endovascular management of nonaortic arterial trauma.We reviewed records of traumatic nonaortic arterial injuries presenting at an urban level 1 trauma center from December 2009-July 2013. Patients undergoing treatment in interventional radiology and patients whose injuries occurred72 h before presentation were excluded. Demographics, indicators of injury severity, operative blood loss, transfusion requirements, and clinical outcome were compared between patients undergoing endovascular and open management using appropriate inferential statistics.During the study period, 17 patients underwent endovascular interventions and 20 had open surgery. There were 19 upper extremity and/or thoracic outlet arterial injuries, 15 lower extremity injuries and 11 pelvic injuries. Endovascular cases were completed using a vascular imaging C-arm in a standard operating room. Estimated blood loss during the primary procedure was significantly lower with endovascular management (150 versus 825 cc, P0.001). No differences were observed between cohorts in age, injury severity score, intensive care unit length of stay, arterial pH, transfusion requirements, inpatient complication rate, or mortality.Our experience with endovascular management demonstrates its feasibility with commonly available tools. Operative blood loss may be significantly decreased using endovascular techniques. Further study is needed to refine patient selection criteria and to define long-term outcomes.

Recent studies have demonstrated an increase in trauma mortality relative to mortality from cancer and heart diseases in the United States. Major vascular injuries such as to the inferior vena cava (IVC) and aortic injuries remain responsible for a significant proportion of early trauma deaths in modern trauma care. The purpose of this study was to explore patterns in epidemiology and mortality after IVC and aortic injuries in the United States.A 13-year analysis of the National Trauma Databank (2002-2014) was performed to extract all patients who sustained IVC, abdominal aortic, or thoracic aortic injuries. Demographics, clinical data, and outcomes were extracted. Patients were analyzed according to injury mechanism.A total of 25,428 patients were included in this analysis. Overall, the mean age was 39.8 ± 19.1 years, 70.3% were male, and 14.1% sustained a penetrating trauma. Although the incidence of all three injuries remained constant throughout the study period, for blunt trauma, mortality decreased over the study period (from 48.8% in 2002 to 28.7% in 2014; P .001), in particular for thoracic aortic injuries (from 46.1% in 2002 to 23.7% in 2014; P .001) and abdominal aortic injuries (from 58.3% in 2002 to 26.2% in 2014; P .001). This decrease in mortality after blunt trauma was accompanied by an increase in endovascular procedures over the study period (from 1.0% in 2002 to 30.4% in 2014; P .001), in particular for blunt thoracic aortic injuries (from 0.7% in 2002 to 41.4% in 2014; P .001). When penetrating trauma patients were analyzed, overall there was an increase in mortality (from 43.8% in 2002 to 50.6% in 2014; P .001), in particular after abdominal aortic injury (from 30.4% in 2002 to 66.0% in 2014; P .001). Similar trends were observed for IVC injuries. No increase in endovascular use in penetrating trauma was identified (from 0.1% in 2002 to 3.4% in 2014; P .001).The present study demonstrates an overall decrease in mortality after blunt aortic injuries in the United States. This decrease was accompanied by an increase in the use of endovascular procedures. After penetrating trauma, however, despite contemporary advances in trauma care, mortality has increased over the study period, in particular after abdominal aortic injury. No increase in endovascular use in penetrating trauma was demonstrated.

Popliteal artery trauma is reported to have the highest rates of limb loss in peripheral vascular injuries. It can be inferred that morbidity associated with bilateral popliteal artery trauma is worse. However, bilateral popliteal artery injuries are sparsely reported in literature and as such management options are not well defined. Despite the paucity of reported cases, a systematic and deliberate approach to these devastating injuries may result in reproducible limb salvage. We hereby use our case report as a provocateur to this conundrum. Consideration should be given to the utilization of surgical shunts or a two-surgical team and limb salvage attempted till proving the neurovascular bundle irreparable. Arterial grafts should be part of the surgeon's armamentarium. In massive hard to control hemorrhage, tourniquets or resuscitative endovascular occlusion devices (REBOA) may prove lifesaving. Larger studies are needed to define contemporary management and derive management guidelines.

To evaluate efficacy and safety of a novel device that combines an inferior vena cava (IVC) filter and central venous catheter (CVC) for prevention of pulmonary embolism (PE) in critically ill patients.In a multicenter, prospective, single-arm clinical trial, the device was inserted at the bedside without fluoroscopy and subsequently retrieved before transfer from the intensive care unit (ICU). The primary efficacy endpoint was freedom from clinically significant PE or fatal PE 72 hours after device removal or discharge, whichever occurred first. Secondary endpoints were incidence of acute proximal deep venous thrombosis (DVT), catheter-related thrombosis, catheter-related bloodstream infections, major bleeding events, and clinically significant thrombus (occupying25% of volume of filter) detected by cavography before retrieval.The device was placed in 163 critically ill patients with contraindications to anticoagulation; 151 (93%) were critically ill trauma patients, 129 (85%) had head or spine trauma, and 102 (79%) had intracranial bleeding. The primary efficacy endpoint was achieved for all 163 (100%) patients (95% confidence interval [CI], 97.8%-100%, P.01). Diagnosis of new or worsening acute proximal DVT was time dependent with 11 (7%) occurring during the first 7 days. There were no (0%) catheter-related bloodstream infections. There were 5 (3.1%) major bleeding events. Significant thrombus in the IVC filter occurred in 14 (8.6%) patients. Prophylactic anticoagulation was not initiated for a mean of 5.5 days ± 4.3 after ICU admission.This novel device prevented clinically significant and fatal PE among critically ill trauma patients with low risk of complications.

Endovascular therapy has been increasingly used for critically injured adults. However, little is known about the epidemiology and outcomes of endovascularly managed arterial injuries in children. We therefore aimed to evaluate recent trends in the endovascular management of pediatric arterial injuries and its association with early survival.An 8-year analysis of the National Trauma Databank (2007-2014) was performed to extract all pediatric trauma patients (aged ≤16 years) with arterial injuries. Demographics, clinical data, interventions (endovascular vs open), and outcomes (in-hospital mortality and length of stay) were extracted. Patients undergoing endovascular or open procedures were compared for differences in clinical characteristics using bivariate analysis. Multivariable logistic regression analysis quantified the association between endovascular therapy and survival in the context of other variables predictive of survival on univariate analysis, with α ≤ .05.There were 35,771 pediatric patients available for analysis. Overall, there was a significant increase in the use of endovascular procedures (from 7.8% in 2007 to 12.9% in 2014; P .001), particularly among blunt trauma patients (5.8% in 2007 to 15.7% in 2014; P .001). Conversely, a significant decrease was noted for open procedures (P .001). There was a stepwise increase in the proportion of patients managed endovascularly as the Injury Severity Score (ISS) increased (highest in the ISS spectrum of 31-50). Angioembolization of internal iliac injury and thoracic aortic endograft placement were the two most common endovascular procedures (n = 88 [33.4%] and n = 60 [22.9%], respectively). There were 331 decedents (9.1% vascular injured children), 242 (73.1%) of whom were dead on arrival. After controlling for differences in demographics and clinical data, when outcomes were compared between patients who underwent endovascular and open procedures, there were no significant differences regarding in-hospital mortality (3.0% vs 3.6%; odds ratio, 0.7; 95% confidence interval, 0.1-6.1; P = .778). A logistic regression model identified Glasgow Coma Scale score ≤8, ISS ≥16, positive result of ethanol or drug screen, and systolic blood pressure 90 mm Hg on admission as independent risk factors for death.The use of endovascular therapy in pediatric vascular arterial trauma has significantly increased, especially among severely injured blunt trauma patients. Despite this successful integration into care, there was no in-hospital survival advantage conferred by endovascular therapy compared with traditional open therapy. Approximately 10% of children with arterial injuries died during initial trauma assessment before therapy could be offered. Glasgow Coma Scale score ≤8, ISS ≥16, positive result of ethanol or drug screen, and systolic blood pressure 90 mm Hg on admission were identified as independent risk factors for death. As children are a population of vulnerable patients, long-term, multicenter studies are required to determine the most appropriate use of and indications for endovascular therapy in pediatric arterial trauma.

Vascular access procedures are commonly performed by acute care physicians within a wide myriad of clinically settings such as the operating room (OR), emergency department (ED), or intensive care unit (ICU) for a wide variety of indications. Regardless of location or indication, vascular access procedures are not innocuous and procedural success traditionally has relied on knowledge of anatomy and familiarity of the procedure. In a prospective study by Schummer et al. (Intensive Care Med 33(6):1055–1059, 2007) that included 1794 cases using landmark techniques, there was a 3.3 % complication rate with vascular catheterization. Also, as the number of passes with the entry needle increases so does the rate of mechanical complication whereby three or more needle passes incurs a six-fold increase in complication rate (Hall and Russell, Anaesthesia 60(1):1–4, 2005). Furthermore, certain subgroups such as children and obese patients have been further identified as having increased risk with vascular access. Although the reported complication rates are relatively low, considering the number of vascular access procedures performed annually as the denominator, the absolute number of complication occurrences becomes significant. Improved assessment of vascular anatomy and visualization during the procedure in an effort to mitigate complications and improve procedural success form the argument supporting ultrasound (US) guided vascular access.

Background Endovascular therapy is well studied in atraumatic conditions; and there appears to be a growing interest in its application to traumatic injuries. The objective of this study is to compare open and endovascular techniques in the management of peripheral arterial trauma. Methods This is a retrospective review of patients admitted to a Level I Trauma Center sustaining injuries to the subclavian, axillary, superficial femoral, and popliteal arteries. Demographics, surgical interventions, complications, and clinical outcomes were evaluated in patients requiring open or endovascular repair between 2009 and 2015. Results Sixty-eight patients with 70 total arterial injuries were identified. There were 10 subclavian, 14 axillary, 15 superficial femoral, and 31 popliteal artery injuries. Endovascular (n = 20) compared to open repairs (n = 50) were more commonly performed: by vascular surgeons (90% vs. 54%, p = 0.01); in older patients (median age: 38 years vs. 25, p = 0.01); primarily involving upper extremity injuries (60% vs. 24%, p = 0.01). Furthermore, endovascular repairs less commonly required fasciotomy (15% vs. 46%, p = 0.03) and trended towards lower transfusion requirements (50% vs. 77%, p = 0.06). Patients undergoing open repair had lower pre-hospital systolic blood pressures (110 vs. 120, p = 0.03) and lower initial hematocrit (31.5 vs. 36.2, p = 0.02). However, outcomes between groups were trending higher in the endovascular group with respect to limb salvage rates at discharge (94% vs. 89%), median length of stay (14 days vs. 9), and median follow-up (288 days vs. 92) compared to the open group, but the data were not statistically significant. There was increasing utilization of endovascular repair over time (7% of total procedures in 2009; 50% in 2014). Conclusions Overall, endovascular and open techniques were not statistically different in early outcomes. Endovascular therapy appears to provide some advantage when it comes to: challenging anatomy, decreasing blood product utilization, and minimizing physiologic derangement. However, patients with injuries resulting in free hemorrhage or significant external blood loss may still be best served with open repair. Despite this, given the increasing use of endovascular techniques, close collaboration is needed between trauma and endovascular specialists to properly select the optimal management for patients with peripheral arterial trauma.

Management of vascular injuries presents a unique set of challenges. Vascular injuries are commonly accompanied by injuries to other organ systems, and affected patients may be critically ill and close to the limits of their physiological reserve. Complications of vascular injury are bleeding, leading to hypovolaemic shock and consumptive coagulopathy, and vascular occlusion causing distal ischaemia and acidosis. When the patient’s clinical condition allows the diagnosis of vascular injuries relies on computerized tomographic angiography or digital subtraction angiography. Control of haemorrhage can be achieved with direct manual pressure, tourniquets for life-threatening extremity haemorrhage, or temporary occlusion with a balloon catheter. Simple surgical repairs may be performed. Ligation is quite well tolerated for arteries of distribution. For patients with significant or ongoing bleeding, a transfusion strategy using a 1:1:1 ratio of packed red blood cells, fresh frozen plasma, and platelets is currently considered the best strategy. For more stable patients, complex and definitive vascular repairs can be considered.

Purpose: To describe the use of custom fenestrated endografts to preserve left subclavian artery (SCA) flow when requiring coverage during endovascular repair of blunt aortic injury (BAI). Case Report: A 39-year-old male involved in a motor vehicle accident sustained injuries including intracranial hemorrhage, BAI, and extremity fractures. Immediate neurosurgical intervention was required. Once neurologically stabilized, endovascular repair was performed with a commercially available device modified with a custom fenestration to preserve flow into the left SCA. Serial follow-up CT angiography (CTA) demonstrates satisfactory repair with prograde left SCA flow and no evidence of endoleak. Conclusion: Left SCA coverage is often required for successful endovascular repair of BAI. A subgroup of patients who undergo left SCA coverage will require revascularization. The use of custom fenestrated endografts for preserving left SCA during thoracic endovascular aortic repair (TEVAR) for BAI is an innovative and feasible option in patients who require revascularization.

Blunt aortic injury (BAI) in young patients with a compliant aorta and evolving hyperdynamic physiology may result in significant variation in aortic diameter during the cardiac cycle. Intravascular ultrasound (IVUS) may be useful to detect real-time variations in aortic diameters for more reliable sizing in patients undergoing thoracic endovascular aortic repair (TEVAR) of BAI.This is a single-institution retrospective study of patients who underwent TEVAR for BAI in a Level 1 trauma center from January 2004 to January 2014. Patients underwent either trauma survey computed tomography (CT) alone (CT group) or IVUS and CT (IVUS group). We compared predeployment aortic measurements, implanted device size, landing zones, and repair outcomes between the groups.Forty-one patients underwent TEVAR for BAI: 28 were in the CT group and 13 in the IVUS group. Left subclavian artery (LSCA) coverage was performed in 50% (CT group) and 38% (IVUS group) of patients. CT-based median aortic diameter was similar in both groups (20.5 mm in the CT group vs. 19.0 mm in the IVUS group, p = 0.374). The median proximal diameter of the proximal device implanted was 26 mm in the CT group and 24 mm in the IVUS group (p = 0.329), which resulted in oversizing of 25.7% and 13.7% (p0.001), respectively. The implanted device was changed in 6 of 13 patients and in 4 of 5 patients in which the LSCA was covered because of IVUS measured-diameters. Graft extension proximal to the LSCA resulted in greater differences between the CT and IVUS measurements of the proximal aorta than if the graft was isolated to the descending aorta (18.8% vs. 5.57%, p = 0.005). Technical success of repair for both groups was 100%; no secondary interventions were required in either group.In combination with CT, IVUS provides important separate sizing information at the point of implantation for more accurate device selection, eliminating need for a repeat CT.Therapeutic study, level IV.

Blunt abdominal aortic injury (BAAI) is a rare and lethal injury requiring surgical management. Injury patterns can be complex and surgical strategy should accommodate specific case circumstances. Endovascular solutions appear appropriate and preferred in certain cases of BAAI, which, however, may not be applicable due to device limitations in regard to patient anatomy and limited operating room capability. However, endovascular therapy can be pursued with limited fluoroscopy capability and consumable availability providing a solution that is expeditious and effective for select cases of BAAI.

Background Blunt injury to the thoracic aorta continues to carry significant mortality and the diagnostic algorithms are evolving as new technology is developed. With improved pre-hospital care, patients with unusual blunt injuries to the aorta may survive to evaluation. While current algorithms for screening focus on the more common blunt injuries to the descending thoracic aorta, our service has seen four injuries to the ascending aorta that have had unusual presentations and presented significant challenges in their management. Methods Retrospective chart review based on a cardiovascular injury database. Results Four patients were identified who survived to hospitalization with an injury to the ascending thoracic aorta. Two were to the ascending aorta and two to the aortic sinuses. Two presented with closed head injury complicating management. One patient presented with aortic valve insufficiency. Motion artifacts at the aortic sinus made screening by CT challenging. These injuries were managed with primary repair (1), tube graft replacement (2), and aortic root replacement with reimplantation of the coronaries (1), all with cardiopulmonary bypass. Conclusion Injuries to the ascending aorta and aortic sinus that survive to evaluation present unique challenges to the screening algorithms. All required cardiopulmonary bypass for repair and potentially complex reconstructions with management decisions affected by the presence of associated injuries. New methodologies such as CT scan gated to cardiac motion may offer higher resolution in this area.

Common femoral vein traumatic injuries are rare. Surgical management is controversial and by nature case specific. In this report, we present an unusual case of an isolated common femoral vein injury from a gunshot blast repaired with an interposition internal jugular vein bypass. To our knowledge, this is the first reported case of an isolated common femoral vein reconstructed in this manner.

Purpose: To describe a damage control open and endovascular approach that successfully repaired a catastrophic retrohepatic injury to the inferior vena cava (IVC). Case Report: A 25-year-old man presented with two gunshot wounds to the trunk. During open operative exploration, a penetrating injury to the IVC behind the caudate lobe of the liver was encountered. To quickly control hemorrhage, en-mass ligation of the injured area and surrounding tissues was performed which resulted in significant IVC stenosis at the level of the repair. After resuscitation in the intensive care unit, the patient was brought back to the operating room where inline flow through the IVC was reestablished by bridging the defect using a 20mm x 55mm covered stent graft. Conclusions: As endovascular expertise and devices become more refined and readily available to treat trauma, variations of this hybrid technique have the potential to become powerful tools to repair retrohepatic IVC injuries.

Acute limb ischemia (ALI) of the lower extremities remains a challenging clinical dilemma despite recent advances in perioperative care, pharmacology, and technology. ALI can be defined as a decrease in limb arterial perfusion occurring within 14 days such that limb viability is threatened. Embolic and thrombotic phenomena constitute the majority of etiologies. The keys to successful outcomes include rapid and accurate diagnosis followed by expeditious intervention to restore limb perfusion.

A principal function of the vascular system is to maintain structural integrity to allow for normal physiologic activity. Insults to this delicate framework due to various forms of traumatic injury severely disrupt the dynamic homeostatic environment of the vascular and hematologic systems, resulting in physiologic derangements – not only within the local setting, but also within the global host environment. Disruption of vessel architecture often manifests as either hemorrhage or thrombosis, which leads to subsequent shock and ischemia. The resulting shift in homeostasis places physiologic stress on nearly every organ system in the body, including the system of coagulation. Corrective maneuvers employed by clinicians addressing hemorrhage and coagulopathy intend to restore normal function of coagulation and while doing so can often simultaneously lead to undesired deleterious effects. This chapter discusses the normal balance of the vascular and hematologic systems, describe the local and systemic sequelae of vascular trauma in reference to coagulation, and review the therapies utilized for treating disturbances in coagulation.

Pregnant adolescent patients afflicted with Takayasu arteritis represent a clinical entity not seen by many. The care of such patients is often managed by multidisciplinary teams, where vascular surgeons are asked to provide input on cardiovascular implications during and after a pregnant state. Knowledge and understanding of the interaction between the two conditions allows for well-informed decision making and favorable outcomes with pregnancy, as well as proper long-term follow-up and care with appropriate clinicians.

BackgroundAcute limb ischemia (ALI) of the lower extremities remains a challenging clinical dilemma. Treatment of ALI has shifted toward endovascular therapies. The purpose of this study was to assess outcomes in patients treated for ALI with intra-arterial thrombolysis and/or adjuvant endovascular techniques.MethodsConsecutive patients with ALI of the lower extremities treated via endovascular intra-arterial methods between January 1, 2005 and September 30, 2007 were identified and reviewed. Comparisons of success, thrombolysis days, and all 30-day outcomes except mortality were performed using generalized estimating equations with logistic and proportional odds regression. Thirty-day mortality was assessed using logistic regression. Long-term patency, limb salvage, and survival were assessed using time-to-event methods, including Kaplan-Meier estimation and Cox proportional hazards models.ResultsThe analyzed dataset included 129 limbs treated in 119 patients presenting with ALI (class I 68%, class IIa 23%, class IIb 9%). The mean follow-up was 16.8 months (range: 0-43 months). Technical success was achieved in 82% cases. The 30-day mortality rate was 6.0% with all 30-day deaths occurring in females (P = .002). One (0.76%) central nervous system hemorrhage (CNS) was noted in this cohort. Primary patency for the entire cohort at 12 and 24 months was 50.1% (95% confidence interval [CI], 39.5-60.7) and 37.7% (95% CI, 26.2-49.1), respectively, while secondary patency was 74.0% (95% CI, 64.9-83.1) and 65.3% (95% CI, 54.5-76.2). Multivariable analyses identified patients presenting with femoropopliteal (hazard ratio [HR] 2.63) or tibial thrombosis (HR 2.80); graft thrombosis (vs native artery thrombosis, HR 2.57) and long-term dialysis (HR 3.66, 95% CI, 2.35-5.71, P < .001) were associated with poorer primary patency rates. Cumulative limb salvage at 24 months was 68.8% (95% CI: 59.5-78.1) with female gender (HR 3.34, P = .002) and thrombolysis ≥3 days (HR 2.35, P = .019) associated with an increased risk of limb loss. Overall 36-month survival was 84.5% (95% CI: 77.5-91.6). Women had decreased survival rates both in the short- and midterm (HR 6.29; 95% CI, 1.78-22.28; P = .004).ConclusionsEndovascular therapy with thrombolysis remains an effective treatment option for patients presenting with lower extremity ALI. Thrombolysis should be limited to