Endovascular repair of subclavian artery injury secondary to internal jugular vein catheterization: case report / Correção endovascular de lesão de artéria subclávia secundária à cateterismo de veia jugular interna: relato de caso

Abstract Background and objectives Ultrasound-guided internal jugular vein catheterization is a common and generally safe procedure in the operating room. However, inadvertent puncture of a noncompressible artery such as the subclavian artery, though rare, may be associated with life-threatening sequelae, including hemomediastinum, hemothorax, and pseudoaneurysm. Case report We describe a case of the successful endovascular repair of right subclavian artery injury in a 75-year-old woman. Subclavian artery was injured secondary to ultrasound-guided right internal jugular vein catheterization under general anesthesia for orthopedic surgery. Conclusion Under general anesthesia several factors such as hypotension can mask the signs of subclavian artery injury. This case report indicates that clinicians should be aware of the complications of central venous catheterization and take prompt action.

Resumo Justificativa e objetivos A cateterização da veia jugular interna guiada por ultrassom é um procedimento comum e geralmente seguro em sala cirúrgica. No entanto, a punção inadvertida de uma artéria não compressível, como a artéria subclávia, embora rara, pode estar associada a sequelas e risco para vida, incluindo hemomediastino, hemotórax e pseudoaneurisma. Relato de caso Descrevemos um caso bem-sucedido da correção endovascular de lesão da artéria subclávia direita em uma paciente de 75 anos. A artéria subclávia foi lesionada após cateterização guiada por ultrassom da veia jugular interna direita sob anestesia geral para cirurgia ortopédica. Conclusão Sob anestesia geral, vários fatores, como a hipotensão, podem mascarar os sinais de lesão da artéria subclávia. Este relato de caso indica que os médicos devem estar cientes das complicações da cateterização venosa central e tomar medidas imediatas.

Pre-diabetes induces ultrastructural alterations in the large blood vessel aorta in rats / La prediabetes induce alteraciones ultraestructurales en la aorta de los grandes vasos sanguíneos en ratas

Excessive consumption of carbohydrate and fat increases the risk of cardiovascular disease. We sought to determine the potential ultrastructural alterations in large blood vessels induced by a high fat and fructose diet (HFD) in a rat model of prediabetes. Rats were either fed with HFD (model group) or a standard laboratory chow (control group) for 15 weeks before being sacrificed. The harvested thoracic aorta tissues were examined using transmission electron microscopy (TEM), and blood samples were assayed for biomarkers of pre-diabetes.TEM images showed that HFD induced profound pathological changes to the aortic wall layers, tunica intima and tunica media ultrastructures in the pre-diabetic rats as shown by apoptotic endothelial cells with pyknotic nuclei, damaged basal lamina, deteriorated smooth muscle cells that have irregular plasma membranes, shrunken nucleus with clumped nuclear chromatin, damaged mitochondria and few cytoplasmic lipid droplets and vacuoles. In addition, HFD significantly (p<0.05) decreased adiponectin and increased biomarkers of lipidemia, glycaemia, inflammation, oxidative stress, vascular injury such as soluble intercellular adhesion molecule-1 (sICAM-1), soluble vascular cell adhesion protein 1 (sVCAM-1), endothelin-1 (ET-1), and coagulation and thrombosis such as Von Willebrand factor (vWF), and plasminogen activator inhibitor-1 (PAI-1), compared to normal levels of these parameters in the control group. Thus, we demonstrated that feeding rats with a HFDisable to develop a pre-diabetic animal model that is useful to study the aortic ultrastructural alterations.

El consumo excesivo de carbohidratos y grasas aumenta el riesgo de enfermedades cardiovasculares. Intentamos determinar las posibles alteraciones ultraestructurales en los grandes vasos sanguíneos, inducidas por una dieta alta en grasas y fructosa (HFD) en un modelo de rata de prediabetes. Las ratas se alimentaron con HFD (grupo modelo) o una comida de laboratorio estándar (grupo de control) durante 15 semanas antes de ser sacrificadas. Los tejidos de la aorta torácica recolectados se examinaron mediante microscopía electrónica de transmisión (TEM) y las muestras de sangre se analizaron para detectar biomarcadores de prediabetes. Las imágenes TEM mostraron que HFD indujo cambios patológicos profundos en las capas de la pared aórtica, túnica íntima y túnica media en la ratas pre-diabéticas como lo muestran las células endoteliales apoptóticas con núcleos picnóticos, lámina basal dañada, células musculares lisas deterioradas que tienen membranas plasmáticas irregulares, núcleo encogido con cromatina nuclear aglomerada, mitocondrias dañadas y pocas gotitas lipídicas citoplásmicas y vacuolas. Además, HFD presentó disminución significativa de adiponectina (p <0,05), y aumento de biomarcadores de lipidemia, glucemia, inflamación, estrés oxidativo, lesión vascular como la molécula de adhesión intercelular soluble 1 (sICAM-1), proteína de adhesión de células vasculares soluble 1 (sVCAM-1), endotelina 1 (ET-1), y la coagulación y la trombosis, como el factor de Von Willebrand (vWF), y el inhibidor del activador del plasminógeno-1 (PAI -1), en comparación con los niveles normales de estos parámetros en el grupo de control. Por tanto, la alimentación de ratas con HFD es capaz de desarrollar un modelo animal prediabético que es útil para estudiar las alteraciones ultraestructurales aórticas.

Vascular injuries during laparoscopic donor nephrectomy and proposed risk reduction strategies

ABSTRACT Introduction: Laparoscopic donor nephrectomy (LDN) has become the standard of care and popular among most of the transplant centres across the globe. Objective of this video is to report different vascular injuries, their management during LDNs and propose risk reduction strategies. Patient and methods: This was a retrospective analysis of all the LDNs performed between January 2011 and March 2016. All donor nephrectomies were performed laparoscopically by transperitoneal route, under ideal operative conditions by expert laparoscopic surgeons and by novice surgeons. Results: 858 LDNs (left, n = 797; right, n = 61) were performed during the study period with 5 cases of vascular injuries. Mean (SD) donor age was 45.5 (± 10.76) years and the operative time was 165 (± 44.4) min. Of these five cases, two had renal vein injury, while the three others had renal artery, inferior vena cava and aortic injury (one each). Four injuries occurred during left LDN and only one during a right LDN. Vascular injuries were managed using the Rescue stitch or metallic clips as indicated. Risk reduction strategy was developed to avoid vascular injuries during LDN, which include - meticulous attention to port placement, addition of fourth port, complete dissection of upper pole and pedicle before clipping, and judicious use of ultrasonic diathermy. Conclusions: Careful evaluation of computed tomography angiography just before surgery will act like a global positioning system (GPS) for the operating surgeon. Rescue stitch is a saviour. Not to panic and being well versed with the risk reduction strategies of laparoscopy and rescue measures is of paramount importance.

Luxación expuesta de rodilla: ¿Qué hemos aprendido en los últimos 20 años? / Open knee dislocations: what have we learn about it in the last 20 years?

INTRODUCCIÓN: La luxación expuesta de rodilla es compleja, de incidencia baja con grandes secuelas funcionales. Existen escasos reportes de series en la literatura relativos a su manejo y resultados. OBJETIVO: El objetivo de este trabajo fue describir los resultados obtenidos de todos los pacientes con luxación expuesta de rodilla tratados durante las últimas dos décadas en nuestro hospital bajo un mismo estándar de tratamiento. MÉTODO: Estudio descriptivo retrospectivo en una serie quirúrgica de 11 pacientes con luxación expuesta de rodilla, tratados entre 1994 y 2015. Todos fueron estudiados y manejados según esquema estandarizado: Angiografía/ angioTC, aseo quirúrgico, fijador externo y reparación neurovascular en casos necesarios. Revisión de registros clínicos e imagenológicos consignando datos demográficos, lesiones concomitantes, número y tipo de cirugías, y complicaciones asociadas. Seguimiento promedio fue de 10,7 años con evaluación mediante encuesta funcionales SF-12/IKDC durante el mes de marzo de 2015. RESULTADOS: Diez pacientes eran hombres, 1 mujeres. Edad promedio al accidente 38,6 años. Mecanismo lesional de alta energía; como referencia la clasificación de Schenck, 1 lesión III-M, 4 tipo IV y los 6 restantes una tipo V. 4 lesiones vasculares (36.4%) y 7 lesiones neurológicas (63.6%). Tratamiento definitivo consistió en 4 reconstrucciones ligamentarias, 2 prótesis, 3 artrodesis y 2 amputaciones supracondíleas. Evaluaciones funcionales dieron como resultados un puntaje promedio de 37 y 48,5 para SF-12 físico y mental respectivamente, y de 44,1 para IKDC. CONCLUSIÓN: La luxación expuesta de rodilla es una lesión infrecuente, muy compleja, asociada a accidentes de alta energía, con complicaciones severas, lo que determina resultados funcionales relativamente malos. La estandarización permite sistematizar las distintas etapas de atención, racionalizar los recursos disponibles evitando la improvisación en momentos críticos, lo que podría incidir en la obtención de resultados.

INTRODUCTION: Open knee dislocation is a complex lesion of low incidence and large functional sequelae. There are few series reports in the literature regarding its management and outcomes. OBJECTIVE: Describe the results obtained from all patients with open knee dislocation treated during the last two decades in our hospital under the same treatment standard. METHOD: Retrospective descriptive study in a surgical series of 11 patients with open knee dislocation, treated between 1994 and 2015. All were studied and managed according to a standardized protocol: Angiography/angioCT, surgical debridement, external fixation and neurovascular repair in necessary cases. Review of clinical and imaging records, recording demographic data, concomitant injuries, number and type of surgeries and associated complications. Average follow-up was 10.7 years, with an evaluation through functional surveys SF-12/IKDC during March 2015. RESULTS: 10 patients were men, 1 woman. Average age at accident 38.6 years. High-energy trauma mechanism of injury; Schenk classification as reference, 1 lesion type III-M, 4 type IV and the remaining 6 type V. 4 vascular lesions (41.7%) and 7 neurological lesions (63.6%). Definitive treatment consisted in 4 ligamentous reconstructions, 2 prostheses, 3 arthrodesis and 3 supracondylar amputations. Functional evaluations showed an average score of 37 and 48.5 for SF-12 physical and mental respectively, and 44.1 for IKDC. CONCLUSION: Open knee dislocation is a rare, very complex, associated to high-energy trauma, with severe complications, which determines relatively poor functional outcomes. Standardization allows to systematize the different stages of attention and rationalize available resources avoiding improvisation at critical moments, which could affect the results.

Trauma vascular na Amazônia: atualizando o desafio / Vascular trauma in the Amazon: updating the challenge

RESUMO Objetivo: avaliar dados epidemiológicos dos pacientes operados por trauma vascular em hospital de referência para traumatismos vasculares do Estado do Pará, determinar as variáveis que aumentam o risco de óbito e fazer uma análise comparativa com os resultados previamente publicados pela mesma instituição. Métodos: estudo retrospectivo analítico realizado através da coleta de dados de pacientes operados por lesões vasculares, entre março de 2013 e março de 2017. Foram analisados dados demográficos e epidemiológicos, como o mecanismo e topografia da lesão, distância entre o local do trauma e o hospital, tipo de tratamento e complicações. Foi feito ainda o estudo de uma matriz de correlação com regressão logística entre as variáveis e a ocorrência de óbito. Resultados: foram estudados 288 pacientes, com 430 lesões; 92,7% era do sexo masculino, 49,7% entre 25 e 49 anos de idade; 47,2% das lesões foi ocasionada por projéteis de arma de fogo; 47,2% das lesões situava-se nos membros superiores, 42,7% nos membros inferiores, 8% em região cervical, 3,1% torácicas e 0,7% abdominais; 52,8% dos pacientes teve hospitalização por sete dias ou menos. Amputação foi necessária em 6,9% e a mortalidade foi 7,93%. Conclusão: distâncias superiores a 200km foram associadas à internação prolongada e maior probabilidade de amputação de membros. Foi encontrada correlação significativa entre a ocorrência de óbito e o fato de haver lesão arterial, lesão vascular na topografia cervical e lesão vascular na topografia torácica.

ABSTRACT Objective: to evaluate the epidemiological data of patients operated on due to vascular trauma at a referral hospital in Pará state, to determine the variables that increase the risk of death, and to make a comparative analysis with the results previously published by the same institution. Methods: an analytical retrospective study was performed through data collection from patients operated due to vascular injuries, between March 2013 and March 2017. Demographic and epidemiological data, such as the mechanism and topography of the lesion, distance between the trauma site and the hospital, and type of treatment and complications, were analyzed. Multivariate analysis and logistic regression studies were performed, to evaluate significant dependence between some variables and death occurrence. Results: two hundred and eighty eight patients with 430 lesions were studied; 92.7% were male, 49.7% were between 25 and 49 years old; 47.2% of all injuries were caused by firearm projectiles; 47.2% of the lesions were located in the upper limbs, 42.7% in the lower limbs, 8% in the cervical region, 3.1% in the thoracic region, and 0.7% in the abdominal region; 52.8% of the patients were hospitalized for seven days or less. Amputation was required in 6.9% of patients and there was mortality in 7.93% of the cases. Conclusion: distances greater than 200km were associated with prolonged hospitalization and greater probability of limb amputation. Significant correlation between death occurrence and arterial injury, vascular injury in the cervical region, and vascular injury in the thoracic region was found.

Complications of Portal Vein Embolization: Evaluation on Cross-Sectional Imaging

Portal vein embolization (PVE) is known as an effective and safe preoperative procedure that increases the future liver remnant (FLR) in patients with insufficient FLR. However, some possible major complications can lead to non-resectability or delayed elective surgery that results in increased morbidity and mortality. Although the majority of these complications are rare, knowledge of the radiologic findings of post-procedural complications facilitate an accurate diagnosis and ensure prompt management. We accordingly reviewed the CT findings of the complications of PVE.

Comparison of Ultrasound-Guided Axillary Brachial Plexus Block Techniques: Perineural Injection versus Single or Double Perivascular Infiltration

PURPOSE: We compared three methods of ultrasound-guided axillary brachial plexus block, which were single, and double perivascular (PV) infiltration techniques, and a perineural (PN) injection technique. MATERIALS AND METHODS: 78 patients of American Society of Anesthesiologists physical status I-II undergoing surgery of the forearm, wrist, or hand were randomly allocated to three groups. 2% lidocaine with epinephrine 5 microg/mL was used. The PN group (n=26) received injections at the median, ulnar, and radial nerve with 8 mL for each nerve. The PV1 group (n=26) received a single injection of 24 mL at 12-o'clock position of the axillary artery. The PV2 group (n=26) received two injections of 12 mL each at 12-o'clock and 6-o'clock position. For all groups, musculocutaneous nerve was blocked separately. RESULTS: The PN group (391.2+/-171.6 sec) had the longest anesthetic procedure duration than PV1 (192.8+/-59.0 sec) and PV2 (211.4+/-58.6 sec). There were no differences in onset time. The average induction time was longer in PN group (673.4+/-149.6 sec) than PV1 (557.6+/-194.9 sec) and PV2 (561.5+/-129.8 sec). There were no differences in the success rate (89.7% vs. 86.2% vs. 89.7%). CONCLUSION: The PV injection technique consisting of a single injection in 12-o'clock position above the axillary artery in addition to a musculocutaneous nerve block is equally effective and less time consuming than the PN technique. Therefore, the PV technique is an alternative method that may be used in busy clinics or for difficult cases.

Caracterización de las lesiones vasculares por tomografía computada (TC) en heridas de arma de fuego: experiencia de tres años en hospital público del sector suroriente de Santiago de Chile / Characterization of vascular lesions in firearm wounds, using computed tomography (CT): three years experience in a public hospital in the southeastern area of Santiago, Chile

Resumen: Objetivos. Conocer las características epidemiológicas y radiológicas en TC, de las lesiones vasculares en pacientes que han sufrido heridas por arma de fuego (HAF), en el servicio de urgencia de un hospital público de Santiago-Chile, en un período de tres anos. Material y método. Revisión retrospectiva de 211 TC realizadas a pacientes ingresados al servicio de urgencia con diagnóstico de HAF entre 31/05/2009 y el 31/05/2012. Se incluyeron pacientes con TC dentro de las primeras 48 horas de ocurrido el evento, excluyendo los pacientes que por su condición clínica, fueron a intervención quirúrgica previa a la TC, obteniendo un N° final de 178. Se analizó la distribución según sexo, edad, tipo de lesión vascular, segmento topográfico afectado, tipo de proyectil y outcome de los pacientes. Resultados. El 96,8 por ciento (n°= 31) de los afectados fueron hombres, 71,8 por ciento menores de 36 años. El segmento más afectado correspondió a las EEII, con un 55,8 por ciento. El tipo de lesión que más frecuente fue el pseudoaneurisma y la hemorragia activa, con un 20,5 por ciento en cada caso. El tipo de proyectil que más frecuentemente se encontró, fueron las balas (65 por ciento) y en la gran mayoría de las veces, sin salida del proyectil. En nuestro grupo hubo un fallecido. Conclusión. Si bien el trauma vascular representa un bajo porcentaje dentro del total de las lesiones por trauma, su extrema gravedad, y por ende necesidad de diagnóstico certero y precoz, explica la importancia del conocimiento y familiarización que los radiólogos deberíamos tener con ese tipo de lesiones. Las extremidades son el principal sitio de lesiones vasculares por herida penetrante, alcanzando hasta el 70 por ciento en nuestro trabajo. En estos casos los exámenes imaginológicos muchas veces son sólo complementarios, porque clínicamente el diagnóstico está hecho, no así en las lesiones de vasos intratorácicos e intra-abdominales, donde las imágenes son indispensables para su...

Objectives. To determine the epidemiological and CT characteristics of vascular lesions in patients who have suffered gunshot wounds, in the emergency department of a public hospital in Santiago, Chile, over a period of three years. Material and Methods. Retrospective review of 211 CT performed on patients admitted to the emergency department with gunshot wounds, between 31/05/2009 and 31/05/2012. Patients with a CT within the first 48 hours after the event occurred were included, excluding patients who for their clinical condition, underwent surgery prior to the CT, obtaining a final number of 178. Distribution was analyzed by sex, age, type of vascular injury, topographic segment affected, projectile type and outcome of patients. Results. 96.8 percent (n° = 31) of those affected were men, 71.8 percent under 36 years. The most affected segment were to the lower extremities, with 55.8 percent. The most frequent type of injury was pseudoaneurysm and active hemorrhage, with 20.5 percent in each case. The type of projectile most frequently found were bullets (65 percent) and the majority, without projectile exit. In our group there was 1 death. Conclusion. Although vascular trauma represents a low percentage of total trauma injuries, their seriousness, and therefore the need for early and accurate diagnosis, explains the importance of the knowledge and familiarity that radiologists should have, with that kind of injury. Extremities are the main site of vascular injury caused by penetrating wounds, affecting up to 70 percent in our sample. In these cases CT examinations are often only complementary because the diagnosis is made clinically; this is not the case in intrathoracic and intraabdominal vessel injuries, where images are essential for diagnosis.

Fluidoterapia de reanimación en pacientes con trauma grave: ¿Necesita cambiarse? / Resuscitation fluid therapy in patients with severe trauma: Is a change necessary?

El acceso venoso en los pacientes politraumatizados ha sido tradicionalmente una medida de suma importancia que permite la administración de líquidos, analgésicos, anestésicos y drogas reanimadoras. Convencionalmente en un paciente exanguinado, la administración vigorosa de cristaloides o coloides estuvo encaminada a restablecer de forma ®empecinada¼ los valores de tensión arterial cercanos a la normalidad, en un intento por lograr la oxigenación tisular adecuada desde el preoperatorio. Sin embargo, se ha demostrado que tal estrategia de reanimación en este tipo de paciente aumenta la morbilidad y mortalidad de este debido a las graves anormalidades metabólicas que provoca, entre ellas la hipotermia, la acidosis, la coagulopatía y el resangrado de las lesiones vasculares previamente autocontroladas por los mecanismos fisiológicos de la coagulación. Hacemos una revisión de la literatura que refleja los relativamente nuevos puntos de vistas en la fluidoterapia de reanimación del paciente politraumatizado exanguinado(AU)

The veined access in the patient politraumatizados has been traditionally a measure of supreme importance that allows the administration of liquids, analgesic, anesthetics and drugs reanimadoras. Conventionally in a patient exanguinado, the vigorous administration of cristaloides or colloids it was guided to reestablish in way ®empecinada¼ the near values of arterial tension to the normality, in an intent to achieve the oxygenation appropriate tisular from the preoperatorio. However, it has been demonstrated that such a reanimación strategy in patient's type increases the morbilidad and mortality of this due to the serious metabolic abnormalities that it causes, among them the hypothermia, the acidosis, the coagulopatía and the resangrado of the vascular lesions previously autocontroladas for the physiologic mechanisms of the clotting. We make a revision of the literature that reflects the relatively new points of views in the fluidoterapia of reanimación of the patient politraumatizado exanguinado(AU)