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The noninvasive vascular laboratory plays a critical role in screening patients at risk for development of abdominal aortic aneurysm (AAA). One-time duplex ultrasound screening reduces aneurysm-related mortality due to rupture and is cost-effective. Population screening based on AAA risk factors is recommended, as it allows for proactive, elective repair of aneurysms at risk for rupture, and surveillance of smaller aneurysms for enlargement. Utilization of societal screening guidelines, such as those published by the Society for Vascular Surgery, can be employed by vascular laboratories to justify individual patient screening, aid primary care physicians to refer patients for testing, and encourage integrated medical health care systems to build prompts in patient electronic health records to ensure compliance with a AAA screening program. Risk factors for developing AAA, that is, age older than 65 years, male sex, family history, and a smoking history of >100 cigarettes, should be used to recommend patient screening, including for women and other elderly (older than 75 years) patients who fall outside of professional societal guidelines.

Objective An endovascular-first approach has been widely adopted as an alternative to surgical bypass in patients who need lower extremity revascularization for femoropopliteal disease. This study evaluated anatomic changes in the extent of bypass and outcomes of open bypass (OBP) surgery after failed endovascular treatment (EVT). Methods We reviewed consecutive patients treated by endovascular femoropopliteal revascularization from 2002 to 2012. Patients requiring OBP after failed EVT were analyzed. Blinded investigators reviewed preoperative and postintervention angiographies. The location of the intended distal anastomosis before the endovascular intervention was compared with the open procedure after failed EVT, and results were analyzed for amputation and patency rates. Results There were 566 patients (322 men [57%]) who underwent 836 endovascular femoropopliteal revascularizations in 665 limbs. Patients were a mean age of 72 ± 11 years. Mean follow-up was 20 months. Indication for revascularization was critical limb ischemia in 33% of patients before the index endovascular procedure. Interventions were performed for de novo lesions in 604 procedures (72%) or restenosis in 232 (28%). TransAtlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease A and B lesions were treated in 547 patients (65%). Balloon angioplasty was used in 822 interventions (98%), with primary or secondary stenting using self-expandable stents performed in 367 (44%). Thirty OBPs were required in 566 patients (5.3%) at an average of 15 months after the index EVT. OBP consisted of 6 above-knee, 14 below-knee, and 10 tibial bypasses. Vein and prosthetic conduits were used equally. Location of the distal anastomosis changed to a more distal target in 13 (5 below-knee and 8 tibial) of 30 patients (43%). Median follow-up was 36 months (range, 0.5-104 months), with a primary patency of 66% at 1 year and 46% at 3 years. Of the 30 bypasses, seven patients required reintervention with percutaneous angioplasty (n = 4) and patch angioplasty (n = 3). Five patients required redo bypass after failed endovascular salvage (lysis or angioplasty, or both), and redo bypass was not attempted in two. Eight patients (27%) progressed to major amputation, for an amputation-free survival of 79% at 1 year and 67% at 3 years. Conclusions OBP after failed EVT was needed in a minority of patients. A change in the bypass target to a more distal site was identified in nearly half of patients. Although an endovascular-first approach to treating claudication and critical limb ischemia is safe and resulted in few progressing to OBP, poor outcomes of open interventions after EVT can be expected if EVT fails.

Managing vascular trauma in an austere environment with limited resources will challenge even the most seasoned surgeon. Successful management requires immediate hemorrhage control, and then, the surgeon must make critical decisions for limb salvage to be successful. This chapter highlights the principles of vascular management and provides damage control techniques that can be applied in a wide array of trauma settings.

Background Endovascular aortic sealing (EVAS) represents a recent transformation in approach for treatment of aortic aneurysms. Initial reporting has shown that EVAS using the Nellix device is safe with similar complication rates to standard endovascular aortic repair (EVAR). What remains unknown is how EVAS technology will behave in the ruptured setting. The purpose of this report is to discuss how EVAS system and endobag technology behave when deployed in a porcine model of aortic rupture. Methods A controlled left retroperitoneal rupture was created in 20 large swine. Following rupture, an EVAS system was deployed across the rupture site to seal the area. The primary end point was seal from ongoing hemorrhage. Other parameters were examined to include endobag extravasation, aortic wall pressure measurements and device behavior in a live tissue model. Results Of the EVAS systems used, 15 Nellix (Endologix, Irvine, CA) devices and 5 novel EVAS systems were used. Of the correctly deployed devices, 100% sealed the rupture (n = 19). One device was deployed above the rupture site, and seal was not achieved secondary to malpositioning. Endobag extravasation was seen with an average protrusion of 7.7 mm. No other areas of aortic injury were noted secondary to endobag trauma. Pressure recording from behind the endobag indicates loss of pulsatile flow to the aortic wall with polymer curing. Conclusions Endovascular aortic sealing for rupture is feasible and performs well in a porcine model of aortic rupture. Polymer extravasation is seen and may be controllable by the implanter. Once the polymer has cured, pulsatile aortic wall pressure is no longer present. EVAS represents an emerging technology for treatment of aortic rupture.

Background Intervention on the great saphenous vein (GSV) has traditionally been limited to the above-knee (AK-GSV) segment for fear of saphenous neuralgia in spite of incompetence demonstrated in the below-knee (BK-GSV) segment. Residual symptoms and need for reintervention are reported to result in nearly half the patients if the refluxing BK-GSV is ignored. Experience with endovenous ablation of the BK-GSV at the time of AK-GSV treatment is sparsely reported in the literature. The aim of this study was to evaluate the safety of endovenous ablation of the refluxing BK-GSV. Methods Data from consecutive patients treated with superficial venous ablation during a 48-month period from January 2010 to December 2013 were retrospectively reviewed. Demographic and procedure-related outcome and complication data were analyzed specifically for patients undergoing BK-GSV interventions. Results A total of 550 patients were treated with superficial venous ablation during the study period. Of those, 61 (79 limbs) underwent BK-GSV ablation for reflux at this site. There were 36 women and 25 men (mean age, 55 years). Median Clinical, Etiologic, Anatomic, and Pathologic (CEAP) score was 3.4; 43 limbs were treated for symptomatic varicose veins (C 1-3) and 36 for advanced venous insufficiency (C 4-6); 14 limbs (18%) were treated for recurrent symptomatic varicose veins or venous insufficiency after prior superficial venous intervention with AK-GSV ablation, sclerotherapy, or stripping. Comorbidities included obesity (54%) with mean body mass index of 30.7 (range, 19 to 52), obstructive sleep apnea (10%), pulmonary hypertension (3%), and congestive heart failure (3%). Ablation was performed in 77 limbs (99%) with the VenaCure EVLT laser vein treatment (AngioDynamics, Queensbury, NY) and in two limbs by radiofrequency ablation with ClosureFAST system (VNUS Medical Technologies, San Jose, Calif). The mean length of GSV ablated was 51.2 cm (range, 26-67 cm). Endovenous ablation was performed concomitantly on 22 accessory GSVs (28%) and 10 incompetent perforators (13%). Ambulatory stab phlebectomy of branch varicosities was performed simultaneously in 59 limbs (75%). All veins treated were evaluated with ultrasound on postprocedure day 1, and no evidence of endovenous heat-induced thrombosis was detected. Eight patients (10%) went on to have preplanned sclerotherapy treatment for small-branch varicosities. Postoperative paresthesia occurred in three patients (4%) and resolved within 4 weeks. Wound infection in three (4%) stab phlebectomy wounds resolved with oral antibiotic therapy. Follow-up surveillance ultrasound was available in 32 of 79 limbs that were >6 months from the procedure. Partial late recanalization was noted in four of 32 limbs, but no patient had recurrent symptoms requiring repeated endovenous ablation during this period. Conclusions Endovenous ablation of the refluxing BK-GSV segment can be performed safely with minimal complications. Consideration should be given to concomitant ablation of the BK-GSV in treatment of patients with varicose veins with reflux extending to the BK segment of the GSV to improve long-term outcomes.

BACKGROUND: The died of wounds (DOW) rate is cited as a measure of combat casualty care effectiveness without the context of injury severity or insight into lethality of the battlefield. The objective of this study was to characterize injury severity and other factors related to variations in the DOW rate. METHODS: The highest monthly DOW (HDOW) and lowest monthly DOW (LDOW) rates from 2004 to 2008 were identified from analysis and casualty report databases and used to direct a search of the Joint Theater Trauma Registry. Casualties from the HDOW and LDOW were combined into cohorts, and injury data were analyzed and compared. RESULTS: The HDOW rates were 13.4%, 11.6%, and 12.8% (mean, 12.6%), and the LDOW rates were 1.3%, 2.0%, and 2.7% (mean, 2.0%) ( p 0.0001). The HDOW (n 541) and LDOW (n 349) groups sustained a total of 1,154 wounds. Injury Severity Score was greater in the HDOW than the LDOW group (mean [SD], 11.1 [0.53] vs. 9.4 [0.58]; p 0.03) as was the percentage of patients with Injury Severity Score of more than 25 (HDOW, 12% vs. LDOW, 7.7%; p 0.04). Excluding minor injuries (Abbreviated Injury Scale score of 1), there was a greater percentage of chest injuries in the HDOW compared with the LDOW group (16.5% vs. 11.2%, p 0.03). Explosive mechanisms were more commonly the cause of injury in the HDOW group (58.7% vs. 49.7%; p 0.007), which also had a higher percentage of Marine Corps personnel (p 0.02). CONCLUSION: This study provides novel data demonstrating that the died of wounds rate ranges significantly throughout the course of combat. Discernible differences in injury severity, wounding patterns, and even service affiliation exist within this variation. For accuracy, the died of wounds rate should be cited only in the context of associated injury patterns, injury severity, and mechanisms of injury. Without this context, DOW should not be used as a comparative medical metric.

Small bowel sources of obscure gastrointestinal bleeding present both a diagnostic and therapeutic challenge. Due to the normal external appearance of the vast majority of small bowel lesions that cause obscure gastrointestinal bleeding, multiple methods of intraoperative localization have been reported. When an arteriographic abnormality is found, the use of vital dye enteric mapping is one of the most effective localization techniques.We present a new technique combining superselective mesenteric angiography with methylene blue enteric mapping and small bowel resection performed during the same operative procedure. This technique was successfully applied in a patient with a jejunal arteriovenous malformation. Included is a review of methods of intraoperative localization with a focus on vital dye staining-guided enterectomy.

BackgroundDespite advances in revascularization following extremity vascular injury, the relationship between time to restoration of flow and functional limb salvage is unknown. The objectives of this study are to describe a large animal survival model of hind limb ischemia/reperfusion and define neuromuscular recovery following increasing ischemic periods.MethodsSus scrofa swine (N = 38; weight, 87 ± 6.2 kg) were randomized to iliac artery occlusion for 0 (Control), 1 (1HR), 3 (3HR), or 6 (6HR) hours, followed by vessel repair and 14 days of recovery. Additionally, one group underwent iliac artery division with no restoration of flow (Ligation), and one group underwent iliac artery exposure only without intervention (Sham). A composite physiologic measure of recovery (PMR) was generated to assess group differences over 14 days of survival. PMR included limb function (Tarlov score) and electrophysiologic measures (compound muscle action potential amplitude, sensory nerve action potential amplitude, and nerve conduction velocity). Using the PMR and extrapolating the point at which recovery following ligation crosses the slope connecting recovery after 3 and 6 hours of ischemia, an estimate of the ischemic threshold for the hind limb is made. These results were correlated with peroneus muscle and peroneal nerve histology.ResultsBaseline physiologic characteristics were similar between groups. Neuromuscular recovery in groups with early restoration of flow (Control, 1HR, 3HR) was similar and nearly complete (92%, 98%, and 88%, respectively; P > .45). While recovery was diminished in both 6HR and Ligation, Ligation, rather than repair, exhibited greater recovery (68% vs 53%; P < .05). These relationships correlated with the pathologic grade of degeneration, necrosis, and fibrosis (P < .05). The PMR model predicts minimal and similar persistent loss of function in groups undergoing early surgical restoration of flow (Control 8%, 1HR 1%, 3HR 12%; P > .45). In contrast, the Ligation group exhibited the greatest degree of injury early in the reperfusion period, followed by more complete recovery and at a faster rate than 6HR. Extrapolating from the PMR the point at which Ligation (68% recovery) crosses the slope connecting 3 hours (84% recovery) and 6 hours (53% recovery) of ischemia estimates the ischemic threshold to be 4.7 hours. Restoration of flow at ischemic intervals exceeding this are associated with less physiologic recovery than ligation.ConclusionIn this model, surgical and therapeutic adjuncts to restore extremity perfusion early (1-3 hours) after extremity vascular injury are most likely to provide outcomes benefit compared with delayed restoration of flow or ligation. Furthermore, the ischemic threshold of the extremity after which neuromuscular recovery is significantly diminished is less than 5 hours. Additional studies are necessary to determine the effect of other factors such as shock or therapeutic measures on this ischemic threshold.Clinical RelevanceRestoration of axial flow following extremity vascular injury is ideally addressed early and definitively. However, in the setting of associated life-threatening and/or orthopedic injuries or prolonged evacuation, the importance of and decision to restore perfusion is guided by a paucity of data. This study provides new insight into the extent of neuromuscular recovery that can be expected after progressive periods of extremity ischemia, to include ligation.

Selective tibial revascularization refers to the practice of vessel repair vs ligation or observation based on factors observed at the time of injury. Although commonly employed, the effectiveness of this strategy and its impact on sustained limb salvage is unknown. The objective of this study is to define the factors most relevant in selective tibial artery revascularization and to characterize limb salvage following tibial-level vascular injury.The cohort of active-duty military patients undergoing infrapopliteal artery repair comprises the tibial Bypass group. A similarly injured cohort of patients that did not undergo operative vascular intervention (No Bypass group) was identified. All tibial vessel injuries were documented by angiography. Data were compiled via medical records and patient interview. The primary outcome measure was failure of limb salvage. Multivariate regression was performed to identify factors associated with revascularization and to describe factors associated with amputation.Between March 2003 and September 2008, 135 of 1332 patients with battle-related vascular injuries had documented tibial vessel disruption or occlusion. Of these, 104 were included for analysis. Twenty-one underwent autologous vein bypass at the time of injury (Bypass group), and the remaining 83 patients were managed without revascularization (No Bypass group). Mean follow-up (39 vs 41 months; P = .27), age (25 vs 27 years; P = .66), and mechanism of injury (88% vs 92% penetrating blast; P = .56) were similar, but the No Bypass group had higher Injury Severity Scores (ISS; 16.3 vs 11.7; P.01). Injury characteristics, including Gustilo III classification (49% vs 43%; P = .81) and nerve injury (55% vs 53%; P = 1.0), were similar. Subjects were more likely to receive tibial bypass with an increasing number of tibial vessel occlusions and documented ischemia on initial exam. However, of the 23 in the No Bypass group with initially unobtainable Doppler signals, 17 (74%) regained pedal flow following resuscitation and limb stabilization. Amputation rates were similar (23% vs 19%; P = .79), but the prevalence of chronic limb pain was lower in the Bypass group (10% vs 30%, respectively; P = .08). Cox regression analysis of amputation-free survival demonstrated an association between mangled extremity severity score5 (hazard ratio [HR], 2.7; P = .01) and amputation.This report provides outcomes data for wartime tibial vascular injury, which supports a selective approach to tibial artery revascularization. Clinical factors such as ISS and degree of ischemia guide which patients are best suited for tibial vascular repair, while injury-specific characteristics are associated with amputation regardless of revascularization status.

ObjectivesThis study characterized temporal changes in the infrarenal aortic aneurysm neck in patients with small, untreated abdominal aortic aneurysms (AAA).MethodsPatients with infrarenal AAA who had contrast-enhanced computed tomography (CT) scans separated by >6 months were identified and their images reviewed. Infrarenal neck diameter and length were measured along with aneurysm diameter. Comparisons between the interval CT scans were made and analysis of factors affecting neck changes performed.ResultsSixty patients met inclusion criteria with an imaging interval of 3.8 years (median, 3.4 years; range, 0.75-9.6 years). During the interval, there was an increase in proximal and distal neck diameters of 1.1 mm (SD, 2.2) (0.28 mm/y) and 1.0 mm (SD, 3.0) (0.26 mm/y), respectively. During the same interval, the neck length decreased by 4 mm (SD, 11) (1 mm/y). A neck length of

BACKGROUND: Temporary vascular shunting to restore flow after vascular injury has been advocated. The effectiveness of this adjunct in protecting against ischemic injury has not been established. This study will assess the temporal impact of shunts on ischemic injury and arterial flow. METHODS: A porcine model of hind-limb ischemia via iliac artery occlusion was used (N = 36; weight [kg] ± SD: 89 ± 4.4). Animals were randomized into one control (Isc(ctrl)) and four study groups (Isc(0), Isc(1), Isc(3), and Isc(6)) according to ischemic time. Shunt placement followed ischemia, and flow and circulating injury markers were collected incrementally during 18 hours of reperfusion. Flow proportions and a calculated Ischemia Injury Index were used to characterize group differences. RESULTS: There were no intergroup differences concerning initial weight, hemodynamic, or laboratory values. Shunt patency was 92% in the absence of anticoagulation. The proportion of common femoral arterial flow to baseline flow in the Isc(6) group was lower than the Isc(ctrl) group (p = 0.02). There was a similar trend with the Isc(1) and Isc(3) groups. The Ischemia Injury Index demonstrated that there was a difference in the Isc(3) and Isc(6) groups (late shunt placement) compared with the Isc(ctrl), Isc(0), and Isc(1) groups (early shunt placement) (p < 0.001). CONCLUSION: This study provides physiologic insight into the benefit of shunts in a model of extremity ischemia. Early shunting protects the extremity from further ischemic insult and reduces circulating markers of tissue injury. Additionally, the presence of a shunt does not increase the Ischemic Injury Index and patency is maintained in the absence of heparinization.

Objective: Decreased morbidity makes endovascular treatment preferable for certain central aortic and great vessel injuries. We present a case of penetrating innominate injury, describe considerations of a catheter-based approach, and provide follow-up of repair. Methods: A case report and review of the literature. Results: A 16-year-old man presented with an isolated innominate artery injury following an air rifle wound. Standard transfemoral approach was used to gain access the innominate artery. The injury was treated with an 8 × 35 mm, balloon-expandable, covered stent. Completion imaging confirmed a well-positioned stent with exclusion of the injury and normal flow in distal vessels. There were no symptoms of stent migration or stenosis 1 year following the injury. Conclusions: Specific anatomic characteristics including its proximity to the carotid and vertebral arteries make the endovascular approach to the innominate artery unique. This case demonstrates the viability of catheter-based approaches in treating vascular injury.

Biochemical markers of ischemia reperfusion injury have been of interest to vascular surgeons and researchers for many years. Acute limb ischemia is the quintessential clinical scenario where these markers would seem relevant. The use of biomarkers to preoperatively or perioperatively predict which patients will not tolerate limb-salvage efforts or who will have poor functional outcomes after salvage is of immense interest. Creatinine phosphokinase, myoglobin, lactate, lactate dehydrogenase, potassium, bicarbonate, and neutrophil/leukocyte ratios are a few of the studied biomarkers available. Currently, the most well-studied aspect of ischemia reperfusion injury is rhabdomyolysis leading to acute kidney injury. The last 10 years have seen significant progression and improvement in the treatment of rhabdomyolysis, from minor supportive care to use of continuous renal replacement therapy. Identification of specific biomarkers with predictive outcome characteristics in the setting of ischemia reperfusion injury will help guide therapeutic development and potentially mitigate pathophysiologic changes in acute limb ischemia, including rhabdomyolysis. These may further lead to improvements in short- and long-term surgical outcomes and limb salvage, as well as a better understanding of the timing and selection of intervention.

The diagnosis of MVT is often overlooked and delayed either until operative exploration for intestinal ischemia or until a cross-sectional imaging procedure is performed. One key to the diagnosis of MVT is clinical suspicion, but CT and MRI are the primary diagnostic modalities. A prior history or family history of a coagulopathy should heighten clinical suspicion. The key to treatment is a rapid diagnosis and systemic anticoagulation to prevent further propagation of the thrombosis.

Once the diagnosis of mesenteric venous thrombosis (MVT) is made, treatment varies with the form of MVT (acute, subacute, or chronic MVT). As with acute arterial mesenteric ischemia, acute MVT is a surgical emergency—it may (and usually does not) require emergency operative or endovascular intervention; acute MVT does require immediate anticoagulation to arrest the thrombotic process and prevent progression to irreversible intestinal venous infarction. Diagnosis (a high index of suspicion) and immediate systemic anticoagulation are requisites with careful observation for development of intestinal infarction requiring operative intervention. For subacute MVT, the treatment is similar—anticoagulation and investigation of underlying risk factors; need for operative or endovascular intervention is unusual. For chronic MVT, treatment involves either anticoagulation if there is an underlying systemic coagulopathy, management of intra-abdominal perivenous pathology if that is the cause of the MVT (e.g., chronic pancreatitis), or management of the hemorrhagic mesenteric or splenic venous consequences of venous hypertension. Interventional processes of thrombectomy/thrombolysis have been used in selected situations but are unusual.

Background Reconstruction of vascular injury often requires use of a conduit, either autologous vein (AV) or expanded polytetrafluorethylene (ePTFE). The most common anatomic locations for and durability of ePTFE as an adjunct to vascular repair in the combat setting are unknown. The objectives of this study were to characterize the anatomic locations of use of ePTFE during the wars in Afghanistan and Iraq and to compare its effectiveness to AV. Methods US service personnel undergoing vascular repair (2002–2012) were identified. Patients in whom ePTFE was used as an interposition conduit ( n = 25) were matched with similar patients who received AV ( n = 24) reconstruction. Injury and operative factors were assessed, and freedom from graft-related complication was quantified using Kaplan–Meier log-rank test. Results There was no difference between ePTFE and AV with regard to age, injury severity, or mangled extremity severity score. Follow-up for the ePTFE and AV groups was 71 and 62 months, respectively. In the cohort there was an apparent but not significantly greater freedom from graft-related complication for AV compared with ePTFE (65% vs. 17%; P = 0.13). In the carotid, subclavian, and axillary artery positions, ePTFE performed equal to AV with no apparent difference in freedom from graft-related complications ( P = 0.90). However, in the periphery, AV demonstrated greater 8-year freedom from graft-related complication than ePTFE (77% vs. 31%, P = 0.044). Conclusions AV is a more durable conduit than ePTFE in repair of wartime extremity vascular injury, whereas ePTFE is effective and durable in the carotid, subclavian, and axillary locations.

Objectives: To determine long-term outcomes of patients needing open renal revascularization (ORR) for stent failure. Methods: Retrospective review was conducted of consecutive patients operated on for renal stent failure from 1998 to 2013. End points were hypertension, renal function response, primary patency, reintervention, and overall and hemodialysis (HD)-free survival. Results: Of 878 ORR during this time, 37 patients (70% female; mean age, 63 6 10 years) had 41 arteries reconstructed for stent failure. Chronic kidney disease (CKD) was stage 2 in 8%, stage 3 in 70%, stage 4 in 19%, and stage 5 in 3%. Reconstructions (bypass 84%) were unilateral in 27 (mean glomerular filtration rate [GFR], 39.9 mL) and bilateral in 10 (mean GFR 47.1 mL). Twelve had ORR of a solitary kidney (mean GFR, 34.1 mL). Three procedure-related deaths occurred at 48, 65, and 210 days due to major adverse events. Overall, five patients needed HD (mean preoperative GFR 35.8 mL vs 43.7 mL in those without HD; P 1⁄4 .29), and three were permanent (8%). Over a mean follow-up of 39 months (range, 2-112 months), mean systolic blood pressure decreased from 153.9 to 134.3 mm Hg (P 1⁄4 NS), and there was a significant decrease in BP medications (2.98 before, 2.47 after; P 1⁄4 .042). There was no change in serum creatinine (1.54 mg/dL before; 1.62 mg/dL after), GFR (43.9 mL before; 45.8 mL after), kidney length (10.6 cm before; 11.0 cm after), or CKD stage (3.1 before and after). Two bypass grafts occluded, one at 5 days and the other at 18 months. One of these patients needed HD, but both eventuated in renal transplant at 8 and 34 months, respectively. Three other grafts needed four endovascular interventions for stenosis at 5, 13, 16, and 17 months after operation. Primary patency was 82% at 5 years. Overall and HD-free survival was 85% at 5 years. Conclusions: ORR for stent failure can be done safely, is durable, requires few late interventions, and has excellent freedom from HD. Patients may gain some improvement in hypertension but have little change in renal function.

The surge in endoluminal treatment of vascular disease has changed both management strategies and outcomes for patients. Renal artery intervention for both renal artery disease and associated vascular anomalies has not been isolated from the transformation in management. This change in treatment strategy has placed renal arteries at risk for iatrogenic injury during treatment. Awareness of the risks, identification of injuries when they occur, and an understanding of the varying modalities available for dealing with injuries is extremely important for the interventionist when caring for and preventing iatrogenic renal artery injuries.

Vascular injury with hemorrhage and ischemia is a significant cause of battlefield morbidity (i.e., amputation) and mortality. Recent reports have demonstrated the rate of vascular injury in modern combat to be five times that reported in previous wars. As a result of the volume of vascular trauma incurred, management of these injury patterns is of special importance. Indeed, approaches to vascular trauma (extremity and torso) have witnessed significant changes during the course of the current wars of Iraq and Afghanistan. Therefore, an appraisal of long-term functional outcomes is warranted.

Military efforts to limit ischemic time and reperfusion injury are being investigated with a focus on functional limb salvage as opposed to the more historic statistical salvage, since a dysfunctional limb may be a worse outcome than amputation. Translatable animal research, supported by reports from forward deployed surgeons in the field, is needed to improve care. Current studies have determined the threshold for meaningful recovery is less than 6 hours. Attempts at modeling vascular injury and ischemia reperfusion can be divided into 2 categories: chronic ischemia that mimics human age related disease and acute vascular injury that represents traumatic injury. A swine model to evaluate battlefield injuries and scenarios encountered in traumatic extremity vascular injury with a focus on functional limb salvage has been developed. Future endeavors should focus on understanding the factors that affect ischemic threshold as well as testing therapeutic and physical maneuvers to prolong this threshold.

Background The modern era has witnessed an increase in endovascular techniques used by physicians to treat vascular injury and age-related disease. As a consequence, the number of open vascular operations available for general surgical education has decreased dramatically. This changing paradigm threatens competence in vascular injury management achieved during surgical residency. The objective of this study is to sample perceptions on vascular injury treatment in the United States to highlight the need for planning for this important tenant of surgical education. Methods An electronic survey was extended to board-certified surgeons through 3 professional societies, the Peripheral Vascular Surgery Society (PVSS), the Eastern Association for the Surgery of Trauma (EAST), and the American College of Surgeons (ACS). Results A total of 520 respondents were self-categorized as trauma (59%; n = 307), vascular (17%; n = 90), or general (19%; n = 99) surgeons. Respondents reported that general surgeons currently manage less than 10% of vascular injuries at their respective institutions. A 2.5-fold increase in endovascular treatment of vascular injury during the past decade was reported with interventional radiologists now involved in the management of up to 25% of injuries. Few general or trauma surgeons surveyed possessed a catheter-based skill set, although 38% of trauma surgeons expressed great interest in endovascular training. Additionally, a cadre of vascular surgeons (67%) affirmed a commitment to teaching vascular injury management. Conclusions The results of this study confirm a diminished role for non–fellowship-trained surgeons in managing vascular injury. Despite an increased acceptance of endovascular techniques to manage trauma, general and trauma surgeons do not possess the skill set. Collaboration between surgical communities will be especially important to maintain high standards in vascular injury management.

Extremity vascular injury during the current war has been defined by anecdotal description and case series. These reports focused on estimation of short-term limb viability and technical description of commonly used adjuncts. Temporary vascular shunting (TVS) has been advocated in current care structures, yet mostly due to war environments, broader statistical scrutiny is lacking. This study's purpose is to provide perspective on TVS's impact on limb salvage, and estimate longer-term freedom from amputation.Data from the Joint Theater Trauma Registry (JTTR), Balad Vascular Registry (BVR), Walter Reed Vascular Registry (WRVR), electronic medical records, and patient interviews were collected on American Troops sustaining extremity vascular injury from June 2003 through December 2007. Those in whom arterial TVS utilization was identified comprise the TVS group. These were compared with controls with similar injury date and anatomic location managed without TVS. Descriptive statistics were employed establishing overall univariate predictors of amputation and comparison between groups. Proportional-hazards modeling, with propensity score adjustment for systemic injury severity and Level 2 care, characterized risk factors of limb loss and effect of TVS. Freedom from amputation was estimated using Kaplan Meier log-rank methods.Cases and controls consisted of 64 and 61 extremity arterial injuries, respectively. Mean follow-up was 22 months (range: 1-54 months). The TVS group was more severely injured (mean injury severity score [ISS]: 18 [SD = 10] TVS vs. 15 [SD = 10] control, P = .05) and more likely to receive Level 2 care (TVS: 26%; control: 10%, P = .02). Overall, a total of 26 amputations occurred (21%). Penetrating blasts, compared with gunshot wounds, were associated with amputation (30% vs. 6%, P = .002). After propensity score adjustment, use of TVS suggested a reduced risk of amputation (relative risk [RR] = 0.47; 95% confidence interval [CI] [0.18-1.19]; P = .11). Venous repair was associated with limb salvage (RR = 0.2; 95% CI [0.04-0.99], P = .05). Associated fracture (RR = 5.0; 95% CI [1.45-17.28], P = .01), and elevated mangled extremity severity score (MESS) ([MESS 5-7] RR = 3.5, 95% CI [0.97-12.36], P = .06; [MESS 8-12] RR = 16.4; 95% CI (3.79-70.79), P.001) predicted amputation. Amputation-free survival was 78% in the TVS group and 77% in the control group at three years (P = .5).Temporary vascular shunting used as a damage control adjunct in management of wartime extremity vascular injury does not lead to worse outcomes. Benefit from TVS is suggested, but not statistically significant. Injury specific variables of venous ligation, associated fracture, and penetrating blast mechanism are associated with amputation. Amputation-free survival after vascular injury in Operation Iraqi Freedom is 79% at three years. Further studies to statistically define any possible benefits of TVS are needed.

Objective The objective of this report was to define the natural history of penetrating aortic ulcers (PAUs) in the descending thoracic and abdominal aorta. Methods Data from consecutive patients with PAU from January 1, 1998 to December 31, 2012 were retrospectively reviewed. Computed tomography (CT) scans were analyzed for anatomic changes. End points analyzed were changes in size, development of symptoms or signs of rupture, morbidity, and mortality. Results Ninety-three patients were identified; 57 were followed up with two or more CT studies 3 months apart (group 1), and 20 had immediate repair (group 2). Sixteen had one CT scan and no intervention or follow-up and were excluded from analysis. In group 1, mean age was 75 years (29 men, 28 women), with 28 descending thoracic aorta and 29 abdominal aorta PAUs. Fifty patients were asymptomatic, whereas five had pain and two had emboli. Mean follow-up was 38 months (range, 3-108 months). Ulcer growth rate was as follows: length, 2.0 mm/y; depth, 1.2 mm/y; and aortic diameter, 2.2 mm/y. Thirteen (23%) went on to repair at a mean of 37 months after diagnosis because of size (54%; 7/13), rapid growth (31%; 4/13), and high-risk morphology (15%; 2/13). During surveillance, 11 patients died, 10 of unrelated causes, and 1 of rupture after refusing repair. All repairs in group 1 were endovascular. The 30-day surgical mortality was 0%. One patient had an access site complication requiring bypass after descending thoracic aorta PAU repair. At a mean follow-up of 32 months, all ulcers were excluded on CT; one (8%) had a type II endoleak. Group 2 included 13 men and seven women with a mean age of 70 years, with 12 descending thoracic and eight abdominal aorta PAUs. Repair indications were rupture (n = 3), symptoms (n = 10), or size (n = 7) and included one open and 19 endovascular repairs with 0% 30-day mortality. Major complications (3/20; 15%) included myocardial infarction, access site disruption, and hematoma; four of 20 patients had type II endoleaks. Conclusions PAU growth rate and risk of rupture are low. Endovascular repair of symptomatic, ruptured, and large PAUs is safe and effective with excellent long-term results. For asymptomatic PAUs, serial CT surveillance is associated with a low rate of rupture or complications.

L’ectasie vasculaire du colon est une condition caracterisee par des veines, des veinules, ou des capillaires sous-muqueux dilates trouves generalement chez des patients presentant une hemorragie gastro-intestinale basse. Nous presentons un cas d’ectasie colorectale associee a une ischemie et a un anevrysme de l’artere mesenterique inferieure. Ces lesions pathologiques peuvent etre le resultat de l’ectasie vasculaire et peuvent s’ajouter a l’histoire naturelle de cette condition.

Tratamiento endovascular de un traumatismo a ortico cerrado en Iraq: extensi on de las capacidades endovasculares innovadoras al campo de batalla Brandon W. Propper, Capt., Joshua B. Alley, Maj., Shaun M. Gifford, Capt., Gabriel E. Burkhardt, Capt. y Todd E. Rasmussen, Lt. Col, Base a erea de Balad, Iraq; Lackland Air Force Base, Texas, Estados Unidos; Bethesda, Maryland, Estados Unidos 332nd Expeditionary Medical Group/Air Force Theater Hos pital, Base a erea de Balad, Iraq. Wilford Hall United States Air Force Medical Center, Lackland Air Force Base, TX 78236, EE. UU. Uniformed Services University of the Health Sciences, Bethesda, MD 20814, EE. UU.

Objectif La prise en charge des traumatismes fermes de l'aorte thoracique descendante est controversee. Malgre l'emergence de preuves vantant les avantages du traitement endovasculaire des traumatismes civils, il n'existe aucune publication concernant l'application de cette strategie dans l'environnement austere de la guerre. Nous rapportons un cas rencontre au 332 eme EMDG/Air Force Theater Hospital, Balad Air Base, en Irak. Methodes Un policier irakien s'est presente avec une rupture traumatique de l'aorte suivant un traumatisme ferme. Le patient avait un hemoperitoine, une fracture faciale de type Le Fort III, une fracture de l'humerus gauche et une rupture traumatique de l'aorte. Apres un packing facial, une stabilisation de la fracture et une laparotomie exploratrice, une aortographie a ete effectuee et a confirme la presence d'une rupture aortique en aval de l'artere sous-claviere gauche. La lesion a ete traitee a l'aide de trois endoprotheses aortiques (extension d'endoprothese pour AAA Gore Excluder® D.C.A.) disposees de maniere sequentielle depuis l'origine de l'artere sous-claviere gauche et couvrant la rupture. Une endofuite de type III a ete traitee avec succes en interposant une extension aortique complementaire. Resultats Le patient est sorti au premier mois suivant le succes therapeutique des autres lesions. Un angioscanner a 10 et 30 jours suivant la procedure n'a montre aucune endofuite et la disparition de l'hematome peri aortique. Conclusion Ce cas detaille le premier traitement endovasculaire d'une lesion traumatique fermee de l'aorte en temps de guerre et represente un engagement en faveur de l'utilisation precoce apres la survenue de la blessure d'une therapeutique endovasculaire innovante. Bien que controversee, cette approche moins invasive est interessante chez des patients ayant des scores lesionnels eleves et particulierement en temps de guerre.

Background The management of blunt descending thoracic aortic injury remains controversial. Despite emerging evidence touting the advantage of endovascular repair in civilian trauma, there have been no reports on the application of this management strategy in the austere environment of war. We provide a case report from the 332nd EMDG/Air Force Theater Hospital, Balad Air Base, Iraq. Methods An Iraqi policeman presented with traumatic aortic disruption following blunt trauma. The patient arrived with hemoperitoneum, a Le Fort III facial fracture, a left humerus fracture, and a thoracic aortic disruption. Following facial packing, fracture stabilization, and damage control laparotomy, aortography was performed, confirming aortic disruption beyond the left subclavian artery. The injury was treated with three aortic cuffs (Gore Excluder® AAA Aortic Extender Endoprostheses) placed in sequence from the origin of the left subclavian across the disruption. A type III endoleak was successfully managed with placement of one additional aortic cuff. Results The patient was discharged after 1 month following the successful treatment of his other injuries. Computed tomography angiography at 10 and 30 days following the procedure revealed no endoleak and a resolved periaortic hematoma. Conclusion This report details the first endovascular treatment of blunt aortic injury in wartime and represents a sustained commitment to advance innovative endovascular capability closer to the time of injury. Although controversial, this less invasive approach is appealing in patients with high injury severity scores, making its availability in wartime especially germane.