Early survival benefit of a low-profile endograft in blunt traumatic aortic injury.

OBJECTIVE: The aim of this study was to demonstrate the safety and effectiveness of a low-profile thoracic endograft (19-23 French) in subjects with blunt traumatic aortic injury. METHODS: A prospective, multicenter study assessed the RelayPro thoracic endograft for the treatment of traumatic aortic injury. Fifty patients were enrolled at 16 centers in the United States between 2017 and 2021. The primary endpoint was 30-day all-cause mortality. RESULTS: The cohort was mostly male (74%), with a mean age of 42.4 ± 17.2 years, and treated for traumatic injuries (4% Grade 1, 8% Grade 2, 76% Grade 3, and 12% Grade 4) due to motor vehicle collision (80%). The proximal landing zone was proximal to the left subclavian artery in 42%, and access was primarily percutaneous (80%). Most (71%) were treated with a non-bare stent endograft. Technical success was 98% (one early type Ia endoleak). All-cause 30-day mortality was 2% (compared with an expected rate of 8%), with an exact two-sided 95% confidence interval [CI] of 0.1%, 10.6% below the performance goal upper limit of 25%. Kaplan-Meier analysis estimated freedom from all-cause mortality to be 98% at 30 days through 4 years (95% CI, 86.6%-99.7%). Kaplan-Meier estimated freedom from major adverse events, all-cause mortality, paralysis, and stroke, was 98.0% at 30 days and 95.8% from 6 months to 4 years (95% CI, 84.3%-98.9%). There were no strokes and one case of paraplegia (2%) during follow-up. CONCLUSIONS: RelayPro was safe and effective and may provide an early survival benefit in the treatment of blunt traumatic aortic injury.

Lower Extremity Vascular Injury in the Pediatric Trauma Patient: Management and Outcomes at an Adult Level I Trauma Center.

BACKGROUND: Traumatic vascular injuries of the lower extremity in the pediatric population are uncommon but can result in significant morbidity. The objective of this study is to demonstrate our experience with these injuries by describing patterns of traumatic vascular injury, the initial management, and data regarding early outcomes. METHODS: In total, 506 patients presented with lower extremity vascular injury between January 1, 2009 and January 1, 2021 to Grady Memorial Hospital, an urban, adult Level I trauma center in Atlanta, Georgia. Thirty-two of the 506 patients were aged less than 18 years and were evaluated for a total of 47 lower extremity vascular injuries. To fully elucidate the injury patterns and clinical course in this population, we examined patient demographics, mechanism of injury, type of vessel injured, surgical repair performed, and early outcomes and complications. RESULTS: The median (interquartile range) age was 16 (2) years (range, 3-17 years), and the majority were male (n = 29, 90.6%). Of the vascular injuries identified, 28 were arterial and 19 were venous. Of these injuries, 14 patients had combined arterial-venous injuries. The majority of injuries were the result of a penetrating injury (n = 28, 87.5%), and of these, all but 2 were attributed to gunshot wounds. Twenty-seven vascular interventions were performed by nonpediatric surgeons: 11 by trauma surgeons, 13 by vascular surgeons, 2 by orthopedic surgeons, and 1 by an interventional radiologist. Two patients required amputation: 1 during the index admission and 1 delayed at 3 months. Overall survival was 96.9%. CONCLUSIONS: Vascular injuries as the result of trauma at any age often require early intervention, and we believe that these injuries in the pediatric population can be safely managed in adult trauma centers with a multidisciplinary team composed of trauma, vascular, and orthopedic surgeons with the potential to decrease associated morbidity and mortality from these injuries.

Using Arterial Pressure Index to Predict Arterial Injuries in Penetrating Trauma to the Upper Extremities.

BACKGROUND: Upper extremity (UE) vascular injuries account for 18.4% of all traumatic vascular injuries. Arterial pressure index (API) use in lower extremity injuries to determine the need for further investigations is well established. However, due to collateral circulation in UEs, it is unclear if the same algorithm can be applied. The purpose of this study was to determine if APIs can be used to determine the need for computed tomography angiogram (CTA) in penetrating UE trauma. METHODS: All adult trauma patients with penetrating UE trauma and APIs from 2006 to 2016 were identified at 3 urban US level 1 trauma centers. Sensitivity, specificity, and positive and negative predictive values of APIs <.9 in detecting UE arterial injuries were calculated. RESULTS: During the 11-year study period, 218 patients met our inclusion criteria. Gunshot wounds comprised 76.6% and stab wounds 17.9%. Median injury severity score and API were 9 and 1, respectively. Seventy-two of our patients underwent evaluation with CTA. Of the injuries, the most common were thrombus or occlusion (46.7%), transection (23.1%), and dissection (15.4%), radiographically. Ultimately, 32 patients underwent surgical.

Missing Bullets: Bullet Embolization Case Series and Review of the Literature.

PURPOSE: Bullet embolization is a rare but dangerous phenomenon. Based on the location of embolization, migration of bullets can cause limb or intra-abdominal ischemia, pulmonary infarction, cardiac valve injury, or cerebrovascular accident. Bullet emboli can present a diagnostic challenge given the varied nature of complications based on location of embolization, which may not coincide with the site of initial injury. The purpose of this study is to present several cases of bullet embolization from our busy urban trauma center and make recommendations for management. METHODS: We present 3 cases of bullet embolization seen in injured patients at our Level 1 trauma center. We describe our management of these injuries and make recommendations for management in the context of our institutional experience and comment on the available literature regarding bullet embolization. RESULTS: Two of our patients presented in extremis and required operative intervention to achieve stability. The intravascular missile was discovered intraoperatively in one patient and removed in the operating room, while the missile was discovered on postoperative imaging in another patient and again removed operatively after an unsuccessful attempt at minimally invasive retrieval. Our third patient remained hemodynamically stable throughout his hospitalization and had endovascular management of his bullet embolus. CONCLUSION: Bullet emboli present a challenging complication of penetrating trauma. We recommend removal of all arterial bullet emboli and those within the pulmonary venous system. In hemodynamically stable patients, we recommend initial attempts of endovascular retrieval followed by open surgical removal. We recommend open removal in cases of hemodynamic instability.

Vascular surgery is the most commonly consulted specialty for emergent operative trauma.

OBJECTIVE: Despite an increasing rate of intraoperative consultation of vascular surgery (VS) for trauma patients, VS is not one of the subspecialties required for American College of Surgeons level I trauma center verification. We sought to assess the rates and patterns of emergent operative VS consultation compared with other surgical subspecialties in the trauma setting. METHODS: A retrospective analysis was performed on all patients who presented with traumatic injuries requiring emergent surgical operations (<3 hours after presentation) from 2015 to 2019 at a level I trauma center. Patient demographics, injury characteristics, and data on consulted surgical subspecialties were collected. The primary outcome measured was the rate of intraoperative consultation to VS and other subspecialties (OS). RESULTS: A total of 2265 patients were identified, with 221 emergent intraoperative consults to VS and 507 consults to OS. After VS (9.8%), the most common subspecialties consulted were orthopedics (9.2%) and urology (5%). Overall, VS was more likely to be consulted in immediate trauma operations (<1 hour after presentation) (65.6% vs 38.1%, P < .0001), penetrating injuries (73.3% vs 47.9%, P < .0001), and at night (60.6% vs 51.9%, P = .02) compared with OS. Time from admission to operation was shorter for cases when VS was involved compared with OS (54.1 ± 40.4 vs 80.6 ± 47.9 minutes, P < .0001). In a multivariable logistic regression model, we found that requiring an immediate operation was associated with higher odds of requiring an intraoperative vascular consult (odds ratio = 1.49, 95% confidence interval = 1.12-2.0). CONCLUSIONS: Vascular surgeons are consulted intraoperatively to assist with emergent trauma at a greater rate compared with specialties that are required for level I trauma center verification. Current American College of Surgeons verification processes and site-specific policies should be re-evaluated to consider VS coverage as a requirement for trauma center verification.

Pre-existing Systolic Dysfunction is the Most Powerful Predictor of Failed Arteriovenous Fistula Maturation.

BACKGROUND: Patients requiring hemodialysis access creation often have significant comorbid conditions, which may impact access maturation. Underlying cardiac dysfunction likely plays an important role in the maturation of arteriovenous fistulae (AVF). The effect of specific parameters of cardiac function on successful AVF creation has not previously been explored. METHODS: A retrospective chart analysis of patients undergoing first-time AVF creation at a single center from 2011 to 2018 was performed. Patients with a transthoracic echocardiogram within the 12 months prior to surgery were included. Standard demographic and perioperative variables were collected, in addition to echocardiographic and vascular mapping data. The primary outcome was access maturation, defined as the use of the access site for hemodialysis at 3, 6, and 12 months after surgery. RESULTS: A total of 121 patients met inclusion criteria with a cumulative AVF maturation rate of 57% (69/121) in this select population. Patients with pre-existing systolic cardiac dysfunction were more than 5 times less likely to see their AVF mature by one year postsurgery (OR = 0.17, P = 0.018). Preoperative venous diameter, access site location, and the type of fistula did not differ significantly between patients with and without systolic dysfunction. Selection of the cephalic vein as the venous anastomosis and diastolic dysfunction (≥ Grade 2) were also associated with lower rates of access maturation, although these associations were less robust. CONCLUSIONS: Systolic cardiac dysfunction is the most important nonmodifiable variable associated with failed AVF maturation. Patients requiring hemodialysis with significant pre-existing cardiac dysfunction may not be appropriate for permanent access creation, and long-term catheter use should be seriously considered as an alternative.

Superior Mesenteric Artery and Vein Injuries: Operative Strategies and Outcomes.

Traumatic injuries to the mesenteric vessels are rare and often lethal. Visceral vessels, such as the superior mesenteric artery (SMA) and vein (SMV), supply blood to the small and large bowel by a rich system of collaterals. Because fewer than 100 such injuries have been described in the literature, they pose challenges in both diagnosis and management and can unfortunately result in high mortality rates. Prompt diagnosis, surgical intervention, and resuscitation can lead to improved outcomes. Here, we review the literature surrounding traumatic injuries of the SMA/SMV and discuss management strategies.

Female gender is associated with increased late luminal narrowing within the stent graft after thoracic endovascular aortic repair.

BACKGROUND: Luminal narrowing, suspected secondary to thrombus, occurs within stent grafts at an unclear incidence after thoracic endovascular aortic repair (TEVAR). The significance of this phenomenon has not been determined, nor have the risk factors for development of intragraft luminal narrowing. Small graft diameter is hypothesized to be a risk factor for the development of ingraft stenosis. METHODS: A retrospective analysis was performed of a multicenter healthcare system including all patients who underwent TEVAR between July 2011 and July 2019 with at least 1 year of subsequently available surveillance contrast-enhanced computed tomography imaging. Standard demographic, preoperative, intraoperative, and postoperative variables were collected. Measurements were obtained via direct off-line images from computed tomography scans. Patent intragraft diameters were compared with baseline and interval change values were normalized to time to follow-up. The primary outcome measure was annual rate of intragraft luminal narrowing. RESULTS: There were 208 patients who met the inclusion criteria (94 women, 114 men) with a median follow-up of 822 days. The mean annual rate of percent intragraft diameter reduction was 10.5 ± 7.7% for women and 7.6 ± 5.6% for men (P = .0026). Multivariate analysis demonstrated female gender (P = .0283), preoperative diagnosis of hypertension (P = .0449), and need for coverage of the left subclavian artery (P = .0328) were all significant predictors of intragraft luminal narrowing. Small aortic diameters were not found to be associated independently with ingraft luminal narrowing nor was the concomitant use of antiplatelet or anticoagulation medications. Significant amounts of ingraft luminal narrowing, defined as a greater than 20% intragraft diameter decrease, were associated with an increased need for any reintervention, including for malperfusion, endoleak, and symptomatic aneurysm (P = .0249). Kaplan-Meier estimates demonstrated a significant gender-associated difference in high rates of intragraft luminal narrowing (P = .00189). CONCLUSIONS: In this analysis, female gender is shown to be a significant nonmodifiable risk factor for intragraft luminal narrowing after TEVAR. The development of this phenomenon is not benign; as such, these findings were associated with an increased need for reintervention. This finding may be attributable to differences in aortic compliance or gender-associated differences in coagulation pathways and merits further investigation. Surveillance after thoracic stent grafting must account for patient-specific variations in complication risk.

Early Results of Popliteal Vein External Banding for Treatment of Chronic Venous Insufficiency.

BACKGROUND: Chronic venous insufficiency (CVI) encompasses a myriad of clinical manifestations including lower extremity swelling and pain, ulcerations and chronic skin changes such as stasis dermatitis, and lipodermatosclerosis. CVI effects greater than 25 million Americans and has a significant socioeconomic and psychosocial impact. Treatment of CVI varies depending on the etiology. For those patients with deep venous reflux, restoration of the deep venous valvular system is critical. Popliteal vein external banding is a novel technique to treat deep venous reflux. Our study aims to retrospectively review the early outcomes for the largest U.S. series of patients undergoing popliteal vein external banding. METHODS: Patients with C4, C5, and C6 disease with underlying deep venous reflux were treated with external banding of the popliteal vein. Basic demographic, ultrasound, and procedural data were collected. Patients were seen in clinic and underwent post procedure duplex. Procedure-specific complications were also assessed. The primary outcome was improvement of symptoms or wound healing. RESULTS: Twelve patients were identified. Seventy-five percent of patients had a history of DVT on the ipsilateral extremity and 66.7% (n = 6) of those patients had previous common or external iliac vein stenting for post-phlebitic syndrome. 58.3% of patients had active ulcerations (C6) at the time of popliteal vein banding and the mean VCSS score was 12.7, consistent with advanced venous disease. Patients were followed for a mean 8.62 months. Of the 8 patients that had active ulcers (C6), 75% completely healed with a mean time to healing of 3.3 months. 91.6% of patients reported clinical improvement in their symptoms (i.e., reduction in edema/swelling, pain or improvement in size of ulcer). Three patients had post-operative wound complications and 1 required oral antibiotic for associated cellulitis. CONCLUSION: Popliteal vein external banding represents a viable treatment modality for patients with venous insufficiency secondary to deep venous reflux. It is technically easier than most deep venous reconstructive options and may have an important role in the multimodal treatment of patients with advanced CVI.

Management and Outcomes after Upper Versus Lower Extremity Vascular Trauma.

BACKGROUND: While significant literature exists regarding peripheral vascular injury management, the vast majority focuses on lower extremity arterial injury. As a result, clinical management of arterial injury in the upper extremities is often guided by literature specific to lower extremity vessel injury. The purpose of this study is to use the largest series of patients reported in the literature to compare management and outcomes of upper and lower extremity traumatic vascular injuries. METHODS: Patients who underwent operative repair of traumatic vascular injuries of the extremities were identified from the trauma registry of a level I trauma center. A retrospective chart review (2011-2019) was conducted. Demographics, mechanism of injuries, operative techniques, and outcomes were compared between patients with upper versus lower extremity vascular injuries. RESULTS: Five hundred thirty-five patients were included with 234 (43.8%) patients undergoing repair of upper extremity vascular injuries. Patients with upper extremity vascular injuries were more likely to be female (16.7% vs. 9%, P = 0.007), have a pre-hospital tourniquet (21.8% vs. 12%,P = 0.002), have associated nerve injuries (40.2% vs. 4.7%, P < 0.0001) or present with bleeding (76.1% vs. 64.1%, P = 0.002) but were less commonly associated with concomitant fractures (25.6% vs. 39.9%, P = 0.0006). There was no difference in age, race, or mechanism of injury. In regards to operative management, upper extremity injuries were more likely to be managed with vessel ligation (38% vs. 17.6%, P < 0.0001) or primary reanastomosis (12.4% vs. 5.6%, P = 0.009) and were less frequently associated with concomitant fasciotomies (13.3% vs. 56.5%, P < 0.0001). Postoperatively, upper extremity injuries were associated with persistent nerve deficits (21.7% vs. 10%, P = 0.0002) while lower extremity injuries had a higher incidence of 30-day limb loss (5.7% vs. 1.3%, P = 0.008). There were no differences in mortality or graft-patency rates between groups. CONCLUSIONS: Upper extremity injuries are associated with a lower limb-loss rate but increased prevalence of neurological deficits after vascular trauma compared to lower extremities. A high level of suspicion is paramount to intraoperative identify associated nerve injuries to improve postoperative functional outcomes.

Stent Graft Oversizing is Associated with an Increased Risk of Long-Term Left Ventricular Wall Thickening in Young Patients Following Thoracic Endovascular Aortic Repair.

BACKGROUND: Left ventricular (LV) wall thickening occurs in patients following thoracic endovascular aortic repair (TEVAR). Clinical consequences of cardiovascular (CV) remodeling may be more significant younger patients with longer anticipated life spans. Risk factors for CV remodeling following TEVAR are unknown but may be related to graft size. METHODS: A retrospective analysis was performed of a multicenter healthcare system including patients aged ≤60 who underwent TEVAR between 2011 and 2019 with at least 1 year follow-up computed tomography angiography imaging available. Standard perioperative variables, native aortic diameter, and stent graft specifications were collected. Graft oversizing was calculated by dividing proximal graft diameter by proximal aortic diameter on preoperative imaging. Posterior LV wall thickness was measured at baseline and interval increases were normalized to time-to-follow-up. Primary outcome was annual rate of posterior LV wall thickening. RESULTS: One hundred one patients met inclusion criteria with a mean (SD) follow-up time of 1270 (693) days. Overall mean (SD) rate of LV wall thickness change was 0.534 (0.750) mm per year. Mean (SD) absolute LV wall thickness at most recent follow-up was 10.97 (2.85) mm for men, 9.69 (2.03) mm for women. Multivariate analysis demonstrated that higher rates of LV wall thickening were associated with narrower graft diameters (P = 0.0311). Greater absolute LV wall thickness at follow-up was associated with narrower grafts (P= 0.0155) and greater graft oversizing (P= 0.0376). Logistic regression demonstrated individuals who met criteria for LV hypertrophy were more likely to have narrower stent-grafts (P= 0.00798) and greater graft oversizing (P= 0.0315). CONCLUSIONS: LV wall thickening occurred to a greater degree in individuals with narrower stent-grafts and higher rates of graft oversizing. This has significant implications for long-term cardiovascular health in younger patients may undergo TEVAR for atypical indications. Particular attention should be paid to long-term effects of stent-graft oversizing when selecting grafts in such populations.

Vascular Surgeons Carry an Increasing Responsibility in the Management of Lower Extremity Vascular Trauma.

BACKGROUND: There is preliminary evidence that vascular surgeons are increasingly relied on nationally to assist with the management of lower extremity vascular trauma. Current trauma center verification, however, does not require any level of vascular surgery coverage. We sought to assess practice patterns regarding vascular surgery consultation and temporal trends in the surgical management of these patients. METHODS: A retrospective analysis was performed on all patients who underwent surgical repair for vascular trauma of the lower extremity at a single, academic, public hospital from 2011 to 2018. Demographic data and procedural data were collected. Patients were assigned to a vascular surgery (VS) or nonvascular surgery (NV) group. The primary outcome measure was the rate of VS consultation. Secondary outcome measures included 30-day mortality, length-of-stay, and limb salvage. RESULTS: One hundred eighty patients were identified (77 VS group, 103 NV group). There was an increase in the proportion of repairs done by VS from 2011 to 2018 (P < 0.05). There were significant management differences between the 2 groups, with vascular surgeons more likely to perform primary end-to-end anastomosis for both arterial (21.33% vs. 6.90%) and venous (19.15% vs. 5.26%) injuries (both P < 0.05). Patients in the VS group were less likely to have balloon embolectomy, fasciotomy, or intravascular shunting than the NV group (all P < 0.05). There were no significant differences in mortality (5.35% vs. 4.85%), length-of-stay (15.05 vs. 18.38 days), or limb salvage (94.81% vs. 95.15%). CONCLUSIONS: Lower extremity vascular trauma is increasingly managed by vascular surgeons. Furthermore, vascular surgeons are more selective in the use of potentially unnecessary adjunctive maneuvers. Current accreditation guidelines should be revisited to mandate vascular surgery coverage in trauma centers that frequently treat this patient population.

Influence of baseline kidney dysfunction on perioperative renal outcomes after endovascular aneurysm repair with suprarenal fixation.

BACKGROUND: Conflicting evidence exists regarding the comparative effects of endovascular aneurysm repair (EVAR) with and without suprarenal fixation. We compare outcomes in patients treated by EVAR with baseline normal kidney function and moderate and severe chronic kidney disease. METHODS: Patients with normal kidney function (glomerular filtration rate [GFR] ≥60 mL/min/1.73 m2) or moderate (GFR = 30-59 mL/min/1.73 m2) or severe (GFR <30 mL/min/1.73 m2) kidney disease who underwent EVAR (N = 5534) were identified from the American College of Surgeons National Surgical Quality Improvement Program targeted database (2011-2015). Groups were determined by the presence (Cook Zenith [Cook Medical, Bloomington, Ind] or Medtronic Endurant [Medtronic, Minneapolis, Minn]) or absence (Gore Excluder [W. L. Gore & Associates, Flagstaff, Ariz]) of a suprarenal fixation system. Postoperative renal complications, defined as rise in creatinine concentration of >2 mg/dL without dialysis or new dialysis requirements, were analyzed within the first 30 days with results stratified by degree of kidney disease. RESULTS: A total of 5534 patients underwent EVAR, with 3225 (58.3%) receiving a device using a suprarenal fixation system. Suprarenal fixation systems were less commonly used for symptomatic patients (11.0% vs 13.7%; P = .002) and patients with ruptured abdominal aortic aneurysm (4.5% vs 6.3%; P = .01). There was no difference in baseline kidney function between groups. EVAR with suprarenal fixation was associated with more renal complications (1.40% vs 0.65%; P = .008). In subgroup analysis, patients with moderate kidney dysfunction (n = 1780) had more renal complications (2.2% vs 0.8%; P = .02) with suprarenal fixation systems. No differences were seen in patients with normal kidney function (0.4% vs 0.2%; P = .32; n = 3597) or severe kidney dysfunction (14.3% vs 10.2%; P = .45; n = 157). This difference was driven mostly by postoperative elevation of creatinine concentration (0.6% vs 0.2%; P = .03) without requirements for new dialysis (0.8% vs 0.4%; P = .08). After adjustments with multivariate logistic regression models, EVAR with suprarenal fixation was associated with more renal complications (odds ratio, 2.65; 95% confidence interval, 1.32-5.34). CONCLUSIONS: In our study, EVAR with suprarenal fixation devices was associated with more perioperative renal complications in patients with moderate kidney dysfunction. Long-term evaluation of these patients undergoing EVAR should be considered.

Pharmacologic Therapy is Not Associated with Stroke Prevention in Patients with Isolated Blunt Vertebral Artery Injury.

BACKGROUND: Vertebral artery injury (VAI) is often grouped with carotid artery injury into a broader classification of blunt cerebrovascular injury, despite fundamental differences in mechanism of injury and outcome. This study seeks to evaluate the efficacy of medical therapy in preventing strokes for isolated VAI. METHODS: Patients with isolated blunt VAI (2011-2018) were identified from the trauma registry of a level I trauma center. A retrospective chart review was conducted excluding patients with concomitant carotid artery injury. Factors examined included demographics, injury characteristics, anatomic classification, and management strategy. Patients were stratified by whether they received pharmacological (antiplatelet or anticoagulation) therapy. The primary outcome was new posterior circulation stroke within 30 days of injury as confirmed by imaging studies. RESULTS: A total of 206 patients with blunt VAI were included. Median Injury Severity Score was 17 and 33 (16.0%) patients presented with Glasgow Coma Scale <8. The most common mechanism of injury was motor vehicle collision (58.7%). The injuries were bilateral in 38 (18.5%) patients and 73 (35.4%) suffered multisegmental injuries. The anatomic severity of injuries was Grade 1 = 38.8%, Grade 2 = 25.7%, Grade 3 = 4.9%, Grade 4 = 30.6%, and Grade 5 = 0.5%. There was no correlation between anatomic grade and stroke (P = 0.11) or initiation of pharmacologic therapy (P = 0.30). In total, 172 (84%) patients received pharmacological therapy with no differences in baseline characteristics between treated and untreated patients. Overall, the 30-day stroke rate was 1.9%. There was no difference in stroke rate between patients who received medical therapy versus those who did not (5.9% vs. 1.2%, P = 0.13). In subgroup analysis by injury severity, medical therapy did not improve stroke rates. Among patients treated with aspirin, there was no difference in stroke rate between doses of 81 vs. 325 mg (1.1% vs. 0%, P = 1). CONCLUSIONS: Isolated VAI is associated with a very low risk of stroke and treatment with medical therapies including antiplatelet or anticoagulation does not improve risk of stroke.

Traumatic Blunt Injuries to the Celiac Artery: A 5-Year Review From a Level I Trauma Center.

BACKGROUND: Injury to the celiac artery secondary to a blunt mechanism of trauma is an extremely rare injury that accounts for only 1%-2% of all visceral vascular lesions. Although rare, this injury is associated with significant mortality. Despite this high mortality, there are currently only a few published case series of blunt celiac artery injuries in the literature. This study sought to review all cases of blunt celiac artery injuries that presented to our Level I trauma center over a 5-year period. METHODS: This was a retrospective chart review of all patients who presented with a traumatic blunt celiac artery injury between January 2012 and March 2017. RESULTS: A total of 10 patients met the inclusion criteria for this study. The majority of patients were male (7/10, 70%), the average age was 38.3 ± 16.1 years, and overall mortality was 20% (2/10). On average, patients spent 10.2 ± 6.5 days in the hospital, 4.4 ± 4.5 days in the ICU, and 1.6 ± 2.0 days on the ventilator. The majority of patients presented with either an intimal dissection (3/10, 30%) or an intraluminal thrombus (3/10, 30%). Other injuries included pseudoaneurysms (2/10, 20%), complete avulsion (1/10, 10%), and an intimal dissection with thrombus (1/10, 10%). Of these injuries, 2 (20%) were noted to have retrograde flow on imaging studies including computed tomography angiography and a visceral angiogram. The majority of patients (8/10, 80%) were managed nonoperatively, and 5 (50%) patients were discharged home on aspirin. One patient who was initially managed nonoperatively required an unplanned return to the operating room for ischemic bowel, liver, and stomach. There were no other complications noted. DISCUSSION: Traumatic blunt injury to the celiac artery is rare. Although there are multiple treatment options, there is currently no consensus in regard to management guidelines. In this case series, the majority of patients were successfully managed nonoperatively suggesting that a selective approach for intervention on patients with a blunt celiac artery injury should be considered.

Rationale and design of a smartphone-enabled, home-based exercise program in patients with symptomatic peripheral arterial disease: The smart step randomized trial.

BACKGROUND: Supervised exercise therapy (SET) is recommended in patients with symptomatic peripheral arterial disease (PAD) as first-line therapy, although patient adoption remains low. Home-based exercise therapy (HBET) delivered through smartphones may expand access. The feasibility of such programs, especially in low-resource settings, remains unknown. METHODS: Smart Step is a pilot randomized trial of smartphone-enabled HBET vs walking advice in patients with symptomatic PAD in an inner-city hospital. Participants receive a smartphone app with daily exercise reminders and educational content. A trained coach performs weekly phone-based coaching sessions. All participants receive a Fitbit Charge HR 2 to measure physical activity. The primary outcome changes in 6-minute walking test (6MWT) distance at 12 weeks over baseline. Secondary outcomes are the degree of engagement with the smartphone app and changes in health behaviors and quality of life scores after 12 weeks and 1 year. RESULTS: A total of 15 patients are randomized as of December 15, 2019 with a mean (SD) age of 66.1 (5.8) years. The majority are female (60%) and black (87%). At baseline, the mean (SD) ABI and 6MWT were 0.86 (0.29) and 363.5 m, respectively. Enrollment is expected to continue until December 2020 to achieve a target size of 50 participants. CONCLUSIONS: The potential significance of this trial will be to provide preliminary evidence of a home-based, "mobile-first" approach for delivering a structured exercise rehabilitation program. Smartphone-enabled HBET can be potentially more accessible than center-based programs, and if proven effective, may have a potential widespread public health benefit.

Perioperative Outcomes for Abdominal Aortic Aneurysm Repair Based on Aneurysm Diameter.

BACKGROUND: Guidelines from the Society for Vascular Surgery recommend elective repair in asymptomatic patients with an abdominal aortic aneurysm (AAA) only if their diameter is greater than or equal to 5.5 cm, yet smaller ones are routinely repaired. This study aims to evaluate perioperative outcomes based on aneurysm size at the time of repair. METHODS: Male patients who underwent elective endovascular aneurysm repair (EVAR) or open abdominal aneurysm repair (OAAR) repair of an infrarenal AAA were abstracted from 2011 to 2015 Targeted National Surgical Quality Improvement Program (NSQIP) database. Patients with symptoms or with aneurysmal extension into the visceral or iliac vessels were excluded. Outcomes of open versus endovascular repair were reported, with multivariate analyses to identify factors associated with the decision to repair AAA ≤5.4 cm. RESULTS: A total of 2115 (90.9%) patients underwent EVAR, while 213 (9.1%) underwent OAAR. The mean diameter in patients who underwent OAAR was 6.1 cm (interquartile range [IQR]: 5.2-6.1 cm) versus 5.7 cm (IQR: 5.2-6.0 cm) for EVAR. However, in 42.5% of EVAR and 32.8% of OAAR patients, the diameter of the AAA was 5.4 cm or less. The group undergoing repair of AAA ≤5.4 cm was younger compared to the larger AAA group (71.9 vs 73.9 years; P < .0001). Patients older than 80 years were less likely to have a repair of AAA measuring ≤5.4 cm (odds ratio [OR] = 0.45, 95% confidence interval [CI] = 0.30-0.65). Additionally, patients who underwent EVAR were more likely to have AAA measuring ≤5.4 cm repaired compared to those who underwent OAAR (OR = 1.62, 95% CI = 1.19-2.21). There were no differences in perioperative morbidity or mortality between the groups. CONCLUSION: There were no differences in perioperative outcomes after AAA repair, independent of aneurysm diameter. We found a higher likelihood of repairing AAA ≤5.4 cm in younger patients who were more likely to have been repaired with EVAR. Patients older than 80 years were less likely to undergo small AAA repair.

Economic burden and clinical impact of preoperative opioid dependence for patients undergoing lower extremity bypass surgery.

OBJECTIVE: Surgeons' prescription practices and the opioid epidemic have received significant attention in the media. Limited data exist, however, on the impact of prior or coexistent opioid use on vascular surgery outcomes. This study aimed to quantify the incidence, economic burden, and clinical impact of pre-existing opioid dependency in patients undergoing lower extremity bypass (LEB) surgery. METHODS: Data were collected from 1,132,645 weighted (230,858 unweighted) patient admissions for LEB in the National Inpatient Sample for the years 2002 to 2015. Patients with a concomitant diagnosis of opioid abuse or dependency were identified using International Classification of Diseases, Ninth Revision codes. Matched cohorts of patients with (n = 606 unweighted) and without (n = 32,343 unweighted) opioid dependence were created using coarsened exact matching to control for patient demographics. Linear regression was used to control for hospital-level factors and to identify differential outcomes for patients with opioid dependency. Our primary end points were hospital cost and length of stay. Our secondary end points were surgical complications and in-hospital mortality. RESULTS: There were 1,132,645 (230,858 unweighted) patient admissions for LEB in the National Inpatient Sample during 2002 to 2015. There were 3190 (0.3%) patients (643 unweighted) who had a diagnosis of pre-existing opioid dependency. The incidence of opioid dependency rose over time (2002, 0.13%; 2015, 0.63%; R2 = 0.90; P < .001). Before matching, opioid-dependent patients were younger (53.9 ± 12.3 years vs 66.7 ± 12.1 years; P < .001) and more likely to be male (65.2% vs 61.9%; P < .001), to be nonwhite (37.9% vs 24.1%; P < .001), to pay with Medicaid (29.6% vs 7.4%; P < .001), and to fall in the lowest income quartile based on ZIP code (39.6% vs 27.5%; P < .001). After matching, opioid-dependent patients (n = 606 unweighted vs n = 32,343 unweighted nonopioid-dependent patients) were at increased risk of surgical site infections (odds ratio [OR], 1.61; P = .006), major bleeding (OR, 1.56; P = .04), acute kidney injury (OR, 1.46; P = .02), and deep venous thrombosis (OR, 2.53; P = .005). Linear regression of matched cohorts revealed that opioid-dependent patients had an increased length of hospital stay (11.76 days vs 9.80 days; P < .001) and an increased mean inflation-adjusted in-hospital cost of U.S. $7032 ($37,522 vs $30,490; P < .001). CONCLUSIONS: The incidence of pre-existing opioid dependency in patients undergoing LEB continues to rise. Patients with opioid use disorder undergoing LEB surgery have substantial increases in length of hospital stay and costs. These findings highlight the importance of early preoperative recognition of this disorder in vascular surgery patients and open the opportunity for early intervention in that cohort.