Reassessing the utility of CT angiograms in penetrating injuries to the extremities.

BACKGROUND: Computed tomography angiography has become routine in the management of penetrating trauma to the extremity. Our objective was to evaluate the efficacy of physical examination findings compared with computed tomography angiography for detection of clinically significant vascular injuries associated with penetrating trauma to the extremity. METHODS: This was a retrospective chart review of patients presenting to a single level 1 trauma center from January 2013-June 2016. Patients with penetrating trauma to the extremity and no hard signs of vascular injury were included. Physical examination and computed tomography angiography findings were analyzed, with particular focus given to missed injuries. RESULTS: We identified 393 patients with penetrating trauma to the extremity without hard signs of vascular injury. Computed tomography angiography was performed in 114 patients (29%). Four patients with distal pulses documented on their initial trauma surveys were found to have vascular injuries on computed tomography angiography, although 3 of these injuries were identified on repeat physical examination. One additional patient had a delayed presentation of a pseudoaneurysm. No mortality or limb loss resulted from these injuries. Total hospital charges for computed tomography angiography amounted to over $700,000. CONCLUSION: Patients with penetrating trauma to the extremity and no hard signs of vascular injury do not require computed tomography angiography for identification of clinically relevant vascular injuries that require emergent operative repair. Serial physical examination appears to provide accurate detection of vascular injury requiring procedural intervention.

Abdominal complications after heart surgery.

BACKGROUND: Up to 3% of patients undergoing heart surgery suffer from an intraabdominal complication (IAC). These complications carry a high mortality besides adding to the morbidity and cost. This review was undertaken to see if a subset of patients with increased risk of IAC could be identified. METHODS: Medical records of 7,731 consecutive patients undergoing heart surgery in a single center were screened for identification of postoperative IAC. One hundred and twenty (120) cases were found. One hundred and six (106) cases were compared with the same number of matched controls. RESULTS: Significant predictors of the development of IAC were increased cardiopulmonary bypass times (> 99 minutes), peripheral vascular disease, chronic steroid use, and low left ventricular ejection fraction. Patients on postoperative antiplatelet therapy or warfarin had a lower risk of IAC. Significant predictors of mortality in IAC were increased cardiopulmonary bypass times (> or = 120 minutes.), use of inotropes, cerebral vascular disease, and incremental age. CONCLUSIONS: A subset of patients can be identified who are at higher risk for IAC and an associated adverse outcome. Patients who have prolonged cardiopulmonary bypass, have a low left ventricular ejection fraction, are on steroids, and suffer from other vascular disease should be observed carefully for development of IAC. Postoperative anticlotting strategies may be helpful. Early diagnosis and intervention are essential for improving outcomes in cases of IAC.

All-terrain vehicle-related maxillofacial trauma in the pediatric population.

PURPOSE: Nearly 40% of all-terrain vehicle (ATV) crash-related fatalities involve pediatric patients, with many of these patients dying from head and neck injuries. West Virginia is in a unique position to examine these injuries because of its high rate of ATV use. This study examines craniofacial ATV-related trauma in children. PATIENTS AND METHODS: We conducted a single-center, retrospective, descriptive study of 26 children presenting with a craniofacial injury(ies) resulting from an ATV crash from January 2001 to December 2004. RESULTS: Twenty-six children (65% boys) with a mean age of 13.1 years presented with craniofacial injuries during the study period. Two patients were helmeted. Mortality was 3.8% (n = 1, head injury related, postinjury day 3). Patients were most often drivers of the ATV (65%), although girls were more likely to be passengers (P = .03). Facial contusions, lacerations, and abrasions were highly prevalent (62%, 69%, 65%, respectively), as were fractures of the facial bones and skull (77%). Thirty-five percent sustained closed head injuries, which were significantly associated with mandible fractures (odds ratio 12.8%; 95% CI, 1.15-143). Mean length of hospital stay was 4.6 +/- 5 days, and 36% required an ICU stay (mean, 5.1 +/- 3 days). Twenty-four percent required ventilator support (mean, 107 +/- 43 hours; range, 48 to 168 hours). Operative intervention was required in 72% of patients (n = 18). CONCLUSION: Maxillofacial injury patterns from ATV-related crashes in children suggest a high percentage of significant facial injuries and closed head injuries. As new ATV legislation that addresses operator use is enacted, a decrease in the number and severity of craniofacial injuries may be seen.

Complications of diagnostic carotid/cerebral arteriography when performed by a vascular surgeon.

Carotid stenting has recently been considered as an alternative treatment to carotid endarterectomy for certain patients with carotid stenosis. Hence, performing carotid arteriography with minimal morbidity and mortality is essential. The purpose of this study was to audit complications of diagnostic carotid/cerebral arteriography performed by a vascular surgeon with experience in endovascular interventions. One hundred one consecutive patients underwent 4-vessel arch aortography with selective carotid, subclavian, and/or vertebral arteriography with use of the Seldinger technique. Demographic data, indications, procedure approach (transfemoral, brachial), number of arteries punctured, type of selective injection, contrast volume, and procedure time were analyzed. Minor complications were those that do not significantly alter the health or activity of the patient or require extra hospitalization or treatment. Other complications were defined as major complications. The technical success rate was 99% (100/101 patients). These included the following: 82 patients with right carotid artery, 82 with left carotid artery, 15 with right subclavian artery, 21 with left subclavian artery, 11 with right vertebral artery, and 17 with left vertebral artery (a total of 228 selective injections). Indications for procedures included the following: transient ischemic attack (TIA)/stroke symptoms in 66%, asymptomatic carotid stenosis in 22%, upper limb claudication in 4%, and vertebrobasilar insufficiency in 4%. Right femoral puncture was used in 79%, left femoral in 12%, and left brachial in 9%. The mean amount of contrast used was 101 cc (45-250 cc) and the mean procedure time was 46 minutes (22-132 minutes). There were 5 complications in the whole series: 3 major complications (3%), including 1 minor stroke (1%) with carotid injection, 1 TIA, and 1 major retroperitoneal bleeding; and 2 (2%) minor complications. The major complication rate in this series compares favorably to published rates of 5.7% to 9.1%. There was no association between complications and specific risk factors except for a longer catheterization time (66 minutes versus 45 minutes, p=0.011). Carotid/cerebral arteriography can be done safely by experienced vascular surgeons with minimal perioperative complications that compare favorably with what has been reported in the radiology literature.