The novel use of resuscitative endovascular balloon occlusion of the aorta for uncontrolled bleeding in a surgically inaccessible abdomen: The ruptured proper hepatic artery in a frozen abdomen.

Hemorrhage is among the leading causes of death for trauma patients. Adjunct techniques used to control bleeding include use of aortic cross clamping, application of a pelvic binder, rapidly expanding hemostatic sponges, and extra-peritoneal packing. Additionally, Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) can provide life-saving proximal control for patients with massive internal hemorrhage. This study concerns a patient treated with Zone 1 REBOA for class IV hemorrhagic shock from a spontaneous common hepatic artery rupture. REBOA was performed at bedside in the Surgical Intensive Care Unit (SICU) prior to definitive selective embolization. A healthy 28-year-old male suffered a grade 4 liver laceration and pancreatic head transection with associated duodenal injury after a high-speed motor vehicle collision. On arrival, the patient required a damage control laparotomy with multiple reoperations for management of his intra-abdominal injuries. By hospital day 11, significant visceral adhesions resulted in a frozen abdomen. On hospital day 20, the patient developed massive hematemesis, hematochezia, and class IV hemorrhagic shock. Vascular surgery was called to bedside in the SICU to perform REBOA. The patient received massive transfusion protocol while a 12 Fr sheath was inserted, and an aortic occlusion balloon was inflated in Zone 1 allowing for hemodynamic stabilization for transport and definitive management in the angiography suite. This case reports a novel use of REBOA, at bedside in the SICU, for the management of a massive gastrointestinal bleed in a patient with frozen abdomen. In this case, REBOA allowed us to achieve temporary hemodynamic stability prior to definitive control in the angiography suite. Bedside use of REBOA in the SICU prevented certain exsanguination and death.

Re-do Hybrid Deep Venous Arterialization via the Popliteal Venous System: Conversion From a Deep Venous Arterialization to a Superficial Venous Arterialization.

Deep venous arterialization (DVA) is a final option for limb salvage in patients with end stage arterial anatomy. We report a 66-year-old dialysis dependent male with forefoot gangrene, Rutherford class 6 chronic limb ischemia, who required a redo endovascular DVA. On initial presentation an angiogram was demonstrated a desert foot with absent tibial runoff to his bilateral lower extremities. After discussion, patient elected to trial DVA in hope of avoiding a major amputation. A hybrid DVA was performed using a Pioneer Plus and .018″ Viabahn stents from the peroneal artery into the peroneal venous system; following this, the peroneal vein was anastomosed to the lesser saphenous vein via an open posterior approach at the ankle. 3 months later, a second DVA was performed by exposing the above knee popliteal artery and vein and creating an end-to-side anastomosis. Of note, the great saphenous vein was less than 2 mm in diameter and no arm vein was available due to history of prior fistulas in bilateral arms. Via the popliteal vein, the posterior tibial vein was selected and additional .018″ Viabahn stents were deployed from the malleolus to the P2 segment of the popliteal vein. Three months after the second hybrid DVA, the patient's forefoot had healed after split thickness skin grafting. Continued patency is noted of the re-do hybrid DVA with minimal calf edema. Newer creative strategies are required for "No Option Chronic Limb Ischemia" which is becoming more relevant in diabetic and dialysis dependent patients. This case illustrates the potential to convert a deep venous arterialization to a superficial venous arterialization for improved venous outflow and wound healing.

Increased Mortality in Patients Transferred to a Level 1 Trauma Center with Blunt and Penetrating Extremity Vascular Injuries.

BACKGROUND: Trauma care depends on a complex transfer system to ensure timely and adequate management at major trauma centers. Patient outcomes depend on the reliability of triage in local or community hospitals and access to tertiary or quaternary trauma institutions. Patients with polytrauma, extremity trauma, or vascular injuries require multidisciplinary management at trauma hospitals. Our study investigated outcomes in this population at a level one trauma center in San Bernardino County, the largest geographic county in the contiguous United States. METHODS: We conducted a retrospective review of all patients with extremity trauma who presented to a single level 1 trauma center over 10 years. The cohort was divided into following two groups: 1. transferred from another medical center for a higher level of care or 2. those who directly presented. Overall, 19,417 patients were identified, with 15,317 patients presenting directly and 3,830 patients transferred from an outside hospital. Extremity of vascular injuries was observed in 268 patients. Demographic data were ascertained, including the injury severity score, mechanism of injury, response level, arrival method, tertiary center emergency department disposition, and presence of vascular injury in the upper or lower extremities. Univariate and multivariate analyses were performed to assess patient mortality. RESULTS: A total of 268 patients with vascular injuries were analyzed, including 207 nontransferred and 61 transferred patients. In the univariate analysis, injury severity score means were compared at 11.4 in nontransferred patients versus 8.4 in transferred (P < 0.001), 50% of blunt injury in the nontransferred group, and 28% in the transferred group (P < 0.001); in-hospital mortality was 4% in nontransferred patients versus 28% in the transferred group (P < 0.001). Multivariate logistic regression demonstrated that mortality is 8 times more likely if a patient with vascular extremity injuries is transferred from an outside hospital. A 10% mortality rate was observed in patients without blood transfusion within 4 hr of arrival to the trauma center and 3% mortality in transferred patients transfused blood. CONCLUSIONS: Extremity trauma with vascular injury can be lethal if managed appropriately. Patients transferred to our level 1 trauma center had a substantial increase in mortality compared with nontransferred patients. Furthermore, the transfer distance was associated with increased mortality. Further research is required to address this vulnerable patient population.

The Use of Advanced Three-Dimensional Computed Tomography During Simple and Complex Endovascular Aortic Aneurysm Repairs.

BACKGROUND: Endovascular aneurysm repair (EVAR) success depends on imaging technology both in the planning and operative phases. Endovascular repair requires intravenous contrast and radiation exposure to the patient as well as radiation exposure to the operator. Recent developments in imaging technology attempt to merge preoperative imaging with intraoperative imaging to improve the efficiency and accuracy of EVAR. The Cydar 3-dimensional (3D) imaging system combines the preoperative and intraoperative imaging during the operation. We aim to investigate the use of the Cydar 3D imaging system during EVAR compared to conventional methods. METHODS: Retrospective review of all patients undergoing an EVAR at a single quaternary vascular center from 2019-2023 was collected. This cohort was divided into 2 groups: (1) repair using Cydar 3D imaging or (2) repair without Cydar 3D imaging. Overall, 138 unique patients were identified with 27 operations using Cydar 3D imaging and 111 operations without Cydar 3D imaging. We performed a 1-to-1 propensity score-matched analysis using nearest-neighbor matching for variables including age, case urgency, and if the case was performed in the operative room or interventional radiology room. A match occurred when a patient in the Cydar 3D imaging group had an estimated score within 0.01 standard deviations of a patient in the control group. From this, we paired 27 from each cohort for a total of 54 patients. Demographic data included length of stay in days, contrast volume (mL), fluoroscopy time (min), procedure length (mins), mortality, and blood loss (mL). Univariate analyses were performed and a P value less than 0.05 was considered statistically significant. RESULTS: A total of 54 vascular patients were analyzed: 27 without the Cydar 3D imaging and 27 with the Cydar 3D imaging. In the univariate analysis, there was no statistical difference in the average length of stay (6.4 days ± 11.76 vs. 4.1 ± 6.03, P = 0.372), aneurysm size (5.9 ± 1.4 vs. 5.9 ± 1.2, P = 0.88), contrast volume in mL (91.3 ± 47.0 vs. 91.1-33.49, P = 9.88), fluoroscopy time in mins (20.2 ± 17.2 vs. 19.5 ± 19.4, P = 0.89), procedure length (299.3 ± 177.9 vs. 353 ± 191.98, P = 0.279), and blood loss in mL (513.8 ± 791 vs. 353 ± 191.98, P = 0.594). There was an increase in reintervention for endoleaks in the group with use of Cydar 3D imaging (0 vs. 6, P = 0.043). A subanalysis of patients undergoing physician-modified EVARs did show a 15% reduction in the contrast volume used. CONCLUSIONS: The use of 3D imaging technology has the potential to increase the safety of EVAR to both patients and operators. In our study, we did not find any difference in standard EVARs; however, there was a contrast use decrease in physician-modified EVARs. Further studies will need to be performed to determine the realized benefit from performing EVARs using this new technology.

Use of the GORE Conformable Excluder Device in Highly Angulated Aortic Neck Anatomy: Mid-term Outcomes.

INTRODUCTION: Patients with complex aortic anatomy require meticulous surgical planning to optimize intraoperative and postoperative outcomes. The GORE Excluder Conformable Abdominal Aortic Aneurysm Endoprosthesis (CEXC Device, WL Gore and Associates, Flagstaff, AZ) allows for endovascular treatment of highly angulated and short proximal neck abdominal aortic aneurysms (AAA). Owing to its recent approval, short-term clinical outcomes of this device remain scarce. REPORT: In this report, we present a case series of 3 patients who underwent endovascular aortic repair using the GORE Excluder Conformable device with highly angulated (>70°) aortic neck anatomy. Endografts were deployed in a radiology suite using standard 2D angiography in conjunction with a CYDAR Medical (Wilmington, Delaware) reconstructed 3D overlay. The patients' ages were 85, 67, and 85 years. The mean abdominal aortic aneurysm diameter in these cases was 6.9 cm. The mean proximal neck length was 2.1 cm, proximal mean neck angulation was 83°. The mean operative time, total fluoroscopy time, and contrast used were 208 minutes, 28.3°minutes, and 94.5 milliliters, respectively. No adjunctive procedures, such as proximal cuff or endo-anchors, were performed at the time of index procedure. DISCUSSION: Type Ia endoleak was observed in 1 patient post-operatively but after treatment with an aortic cuff there was no evidence of enlarging aneurysm sac. The GORE Excluder Conformable Endoprosthesis expands access to endovascular management of AAAs. Our early experience with this device demonstrated excellent patient and clinical outcomes in a highly angulated neck anatomy.

Tracheal ulcer development from high volume, low-pressure cuffed endotracheal tubes.

INTRODUCTION: Iatrogenic injury to the larynx, particularly the vocal cords from prolonged intubation, has been well-studied; however, tracheal injuries are rarely reported. This study investigates the effectiveness of cuffed, high-volume, low-pressure endotracheal tubes in preventing the development of tracheal ulcers in intubated subjects. METHODS: A retrospective, IRB-approved review was performed on 1355 subjects who underwent percutaneous tracheostomy from 2002 to 2018. The presence and severity of tracheal ulcers were collected using documentation and photos during percutaneous tracheostomy placement. Primary outcome measures included: the length of time on a ventilator until tracheostomy (LOVT), length of hospitalization (LOH), and mortality in relationship to the severity of the tracheal injury. Data was reported as n (%) and median (IQR). The differences in means between groups were analyzed by ANOVA and Chi-square test with an alpha of 0.05. RESULTS: 206 subjects met the inclusion criteria; 65 subjects had an absence of tracheal injury, and 141 subjects developed tracheal ulcers. Subjects with tracheal ulcers were grouped by the following severity scale: no ulcer; mild ulcer (minimal mucosal erosion with exudate); moderate ulcer (mucosal erosion); and severe (tracheal ring exposure). There were no statistically significant differences in age (p = 0.99), gender (p = 0.83), BMI (p = 0.44), LOH (p = 0.88), LOVT (p = 0.93), and mortality (p = 0.306) between subjects with differing severity of ulcers. The average annual incidence of clinically significant ulcers (moderate and severe) was 2.2 %. CONCLUSIONS: The lack of statistical correlation between the duration of intubation and tracheal ulcer severity, along with a low annual incidence of tracheal ulcers, supports the improved safety of high-volume, low-pressure cylindrical, cuffed endotracheal tubes. This study is among the first to specifically focus on injuries at the level of the cuff and tip of endotracheal tubes with implications in preventive measures and potential product design changes.

The Impact of Computed Tomography Scans on the Management and Wait Times in Perianal Abscess Diagnoses.

Background Diagnosis and management of perianal abscesses (PAA) are based on history and clinical examination. Imaging is not indicated except in complicated cases, as determined by the surgical team. The monetary, ionizing radiation, and resource utilization costs of a computed tomography (CT) scan in the emergency room must be considered when used for diagnostic purposes of PAAs. Methods A retrospective analysis of 129 patients diagnosed with a diagnosis of PAA between 2015-2020 was performed. The primary endpoints included length of stay, CT performed, time from patient presentation to CT, and CT scan completion prior to surgical consultation. Data is reported as n (%) or median (IQR). Results Of the 129 patients diagnosed with PAA, 81 underwent CT, and 48 did not. General surgery was consulted in 88% of cases. There were no statistically significant differences in age (p=0.562), sex (p=0.531), or ethnicity (p=0.356). The median hospitalization time was two days when CT was performed (p=0.001). The median time elapsed from presentation to the emergency department and CT scan performed was 16 hours (p=0.001). CT scans were ordered before the surgical consultation in 65% of cases (p=0.001) and 17% after a surgical consultation was placed (p=0.009). Conclusion Performing CT scans prior to surgical evaluation for the diagnosis of PAA is not a responsible practice. The cost, resources, and radiation exposure must be considered. This study demonstrated that more CT scans are ordered prior to surgical consultation for PAA, resulting in a prolonged wait time in the emergency department.

Penicillin-resistant gonorrheal endocarditis presenting with large annular abscess and aortic valve destruction.

Disseminated gonorrheal infections with cardiac involvement are rare, with fewer than 100 cases reported. The increasing prevalence of gonococcal infections and increasing antibiotic resistance represent a concerning challenge to public health. Here we report a case of antibiotic-resistant gonococcal endocarditis presenting with cardiogenic shock and discuss principles of diagnosis and treatment.

A Multicenter Analysis of Revision of Aneurysmal Dialysis Access Using Bovine Carotid Artery Conduit.

BACKGROUND: Dialysis access complications and failure requiring revision are common. Understanding which methods of revision yield the optimal patency rates and lowest complications remain in evolution. Revision of native vessels is preferred, with revision using expanded polytetrafluoroethylene (ePTFE) graft as an alternative. Revision with Bovine Carotid Artery Graft (Artegraft) has historically been indicated when other options have been exhausted. While earlier studies demonstrated lower patency and higher infection rates compared to ePTFE, more recent studies have suggested otherwise. We describe our experience with patients who underwent arteriovenous access revision with Artegraft, and present this as a viable alternative. METHODS: A multicenter analysis was conducted over 6 years of 25 patients with arteriovenous access complications requiring revision. Complications included aneurysmal degeneration, bleeding, recurrent thrombosis, and sclerotic outflow. Patients were grouped into 2 groups based on the complication. The first group included aneurysm-only complication and the second group included aneurysm and all other complications. All patients underwent revision of their arteriovenous fistula with excision of diseased segment of the arteriovenous fistula and interposition placement of Artegraft. All patients were followed long term and assessed for postop complications, patency, and any reintervention. RESULTS: Of 25 patients, 13 were male and 12 female. Average age was 57 (range 27-83). Sixteen of the 25 patients had follow-up. Of the 16, 10 patients had primary patency (62.5%), 3 with primary-assisted patency (18.75%), and 3 with failure of grafts (18.75%). Ten of the 16 had at least 1 year or greater follow-up (5 with primary patency, 3 primary-assisted patency, and 2 with failure both of which failed after 1 year). Those that required intervention to maintain patency were from thrombosis requiring declot or anastomotic stenosis requiring angioplasty. None of the followed patients were found to have neither postoperative surgical site nor graft infections. CONCLUSIONS: This case series supports that arteriovenous access revision with Artegraft is a viable option that has acceptable patency rates (81% overall functional patency rate at 1.5 years), with an observed 0% infection rate, and is comparable to ePTFE. With more recent studies suggesting Artegraft may have superior outcomes, further study and consideration should be given to using Artegraft as a conduit for arteriovenous fistula revision.

A Comparative Analysis of Critical Limb Ischemia in the Intensive Care Unit since the COVID-19 Pandemic.

BACKGROUND: Emerging data and case reports have found coagulation abnormalities and thrombosis as sequelae of infection with SARS-CoV-2 (COVID-19). Case reports have reported thrombotic complications caused by COVID-19-related coagulopathy leading to limb loss. Alarmingly, many of these patients had no underlying vascular disease prior to being infected with COVID-19. Many of these case reports discuss patients developing gangrene in the intensive care unit (ICU). Our study compares the incidence of gangrene in the ICU in COVID-19 patients to baseline inpatient levels prior to the pandemic. METHODS: This retrospective analysis investigates two subsets of patients from a single institution. The first was from 2020 during the COVID-19 pandemic; the second subset was from 2019 before the pandemic. Demographic data and medication history were ascertained for both groups. Primary outcomes measures included extremity gangrene that developed in the ICU, mortality, and major amputation. RESULTS: There were 249 COVID-19 positive patients admitted to the ICU in 2020. In 2019, 1,846 admissions to the ICU took place, of which 249 patients were randomized to chart review. There were 13 cases of gangrene that developed in the ICU, 12 of which took place in 2020. In-hospital mortality was 11.6% in nonCOVID-19 patients in 2019 vs. 41.4% in 2021 (P < 0.001). Only 16.7% of the COVID-19 gangrene patients had previously known arterial disease. Also, patients in the COVID-19 group with gangrene were four times more likely to be smokers (P = 0.004). When the data were stratified to compare between gangrene development and no gangrene development, the combined total gangrene group had longer hospital stays, higher need for blood transfusions, required major amputations, and revascularization. A multivariate logistic regression from the total study similarly demonstrated that COVID-19 infection is associated with an 18.23 times increased risk of gangrene. CONCLUSIONS: COVID-19 has resulted in an incomprehensible societal impact that will linger for years to come. The last 2 years have reinforced that COVID-19 will be a part of our clinical practice indefinitely. This study emphasizes the importance of clinician awareness of COVID-19 induced critical limb ischemia in those without underlying arterial disease and few medical comorbidities. More research efforts toward preventing limb loss and COVID-19 coagulopathy must be performed expeditiously to achieve a better understanding.

Regional abdominal wall nerve block versus epidural anesthesia after hepatectomy: analysis of the ACS NSQIP database.

BACKGROUND: The aim of this study is to determine whether regional abdominal wall nerve block is a superior to epidural anesthesia (EA) after hepatectomy. METHODS: Patients undergoing open hepatectomy in the NSQIP targeted file (2014-2016) were identified. Those with INR > 1.5, Platelets < 100, bleeding disorders, undergoing liver ablation without resection, and spinal anesthesia were excluded. Patients with regional abdominal wall nerve block (RAB), mostly transversus abdominis plane (TAP) block, were matched (1:1) to those undergoing EA using propensity scores to adjust for baseline differences. RESULTS: Out of 1727 patients who met our inclusion criteria, 361 (21%) had RAB. Of whom 345 were matched (1:1) to those who underwent EA. The matched cohort was well-balanced regarding preoperative characteristics, extent of hepatectomy, concurrent ablations as well as biliary reconstruction. RAB was associated with shorter hospital stay (median: 6 days vs. 5 days, p = 0.007). Overall morbidity (44.1% vs. 39.4%, p = 0.217), serious morbidity (27% vs. 25.2%, p = 0.603), and mortality (2.6% vs. 2.3%, p = 0.806) were not different between the two groups. Individual complications, readmission rate, and blood transfusion were not different between the two groups. CONCLUSION: Regional abdominal nerve block is associated with shorter hospital stay than epidural anesthesia without an increase in overall postoperative morbidity or mortality. RAB is a viable alternative anesthesia adjunct to EA in patients undergoing hepatectomy. However, given the retrospective nature of this study further studies comparing the modalities should be considered to definitively define the utility of RAB.

A unique finding of the basilar artery.

Variants of the posterior intracranial circulation are important for surgeon, interventionalists and radiologists. Herein, a unique configuration of the basilar artery is reported. A 54-year-old man with a history of COPD, hypothyroidism, smoking, and hyperlipidemia presented to an outside institution with nausea, confusion, altered mental status, and ataxia. The patient was evaluated for stroke. Imaging revealed rotation of the basilar apex of 180 degrees, fetal configuration of the posterior communicating artery, right posterior cerebral artery filling from the left vertebral artery, and duplication of the left and right superior cerebellar arteries. The patient continued to deteriorate neurologically and MRI revealed multifocal and symmetric signal abnormalities in the brain stem, thalami, basal ganglia, and hippocampi. The differential diagnosis included acute disseminated myeloencephalitis. Despite plasma exchange and steroid therapy, the patient died a few days later. This case report demonstrates a rare variation of the basilar apex.

An Interesting Civilian Case of Complex Maxillofacial Trauma Due to Target Fragmentation Following Bullet Impact and Review of the Branches of the Maxillary Artery.

Serious morbidity and mortality for the operator and bystanders are associated with a lack of knowledge and failure to utilize appropriately manufactured targets. The management of firearm-related facial trauma is challenging and requires rapid intervention from a multidisciplinary team. We present a case of penetrating facial trauma secondary to the fragmentation of a homemade target. We highlight how firearm operators can optimize safety by matching ballistics with target selection and review pertinent vascular structures, including the terminal branches of the external carotid artery and branches of the maxillary artery. This case demonstrates that trauma physicians must be well-versed with complex maxillofacial anatomy and multimodal approaches to hemostasis.

A Traumatic Dislocation of the Atlas from the Axis in a Patient with Atlantooccipital Assimilation.

Atlantooccipital assimilation is defined as the complete or partial fusion of the caudal portion of the occiput with the cranial portion of the atlas. We report an extremely rare case of a traumatic dislocation of the atlas from the axis (C1 from C2), which lead to internal decapitation in a patient with atlantooccipital assimilation. This report reviews the background of atlantooccipital assimilations and their clinical relevance.

Gerber's Ligament-A Forgotten Structure of the Craniocervical Junction.

BACKGROUND: Ligaments of the craniocervical junction play a critical role in stabilizing this region. Gerber's ligament has more or less been forgotten and, to our knowledge, never studied. METHODS: Dissection of the craniocervical junction was performed in 15 fresh frozen cadavers. In the prone position, the posterior elements of the upper cervical vertebrae and occiput were removed. After removing the contents of the spinal canal and posterior cranial fossa, the dura mater and tectorial membrane were reflected. The superior band of the cruciform ligament was reflected. When Gerber's ligament was identified, its attachments and morphometry were recorded. Lastly, Gerber's ligament was observed while range of motion of the craniocervical junction was performed. RESULTS: Gerber's ligament was identified in 7 specimens (46.7%). This structure arose anteriorly from the junction of the superior band and transverse part of the cruciform ligament. Gerber's ligament was always found to be just deep to the superior band of the cruciform ligament but traveled more anteriorly to attach onto the posterior aspect of the dens approaching, but not attaching onto, its apex. Mean length was 11 mm, and mean width was 7 mm. Thickness of the ligament was 0.5-1.1 mm. The ligament was found to become taut with minimal rotation of the atlantoaxial joint and extension of the craniocervical junction. CONCLUSIONS: A good understanding of all ligaments of the craniocervical junction is important to surgeons and physicians treating patients with injury to the upper cervical spine.

An Unusual Finding of the Hyoid Bone.

The hyoid contributes to many biomechanical processes including swallowing. Additionally, the hyoid bone has been studied for over a century in an effort to catalog and categorize many observed biometric differences. This has led to the hyoid being a major structure involved in forensic pathology. In this paper, we discuss a very unusual finding of an adult female hyoid bone.

Henle's Ligament: A Comprehensive Review of Its Anatomy and Terminology over Almost One and a Half Centuries.

Henle's ligament was first described by German physician and anatomist, Friedrich Henle, in 1871. This review article will cover Henle's original description of the ligament, historical changes in terminology, embryological studies of the ligament, and the clinical significance of Henle's ligament. This article has a particular focus on the variation in the terminology of this structure and the implications of this.