Distal Adjuncts for High-Risk Lower Extremity Bypasses.

BACKGROUND: This review will discuss the use of distal adjuncts for improving graft patency in high-risk lower extremity bypasses. METHODS: Factors that contribute to the increased risk of failure in high-risk lower extremity bypasses, such as the use of nonautogenous conduits, the creation of bypasses to very distal arterial targets, and bypasses in patients with significant tibial arterial disease, will be discussed. RESULTS: The use of surgical techniques such as creating venous cuffs, venous patches, and arteriovenous fistulas have been shown to improve the patency of high-risk bypasses. CONCLUSIONS: Despite the increased risk of failure, the use of surgical adjuncts such as cuffs, patches, and arteriovenous fistulas can improve the patency rates of high-risk lower extremity bypasses.

Association Between Obesity and Outcomes Following Endovascular Aneurysm Repair.

BACKGROUND: Obesity is prevalent in patients with abdominal aortic aneurysms (AAA). There is an association between increasing body mass index (BMI) and increased overall cardiovascular mortality and morbidity. This study aims to assess the difference in mortality and complication rates between normal weight (NW), overweight (OW), and obese patients undergoing endovascular aneurysm repair (EVAR) for infrarenal AAA. METHODS: This is a retrospective analysis of consecutive patients undergoing EVAR for AAA between January 1998 and December 2019. Weight classes were defined as: BMI<18.5 kg/m2, underweight; BMI 18.5-24.9 kg/m2, NW; BMI 25.0-29.9 kg/m2, OW; BMI 30.0-39.9 kg/m2, obese; BMI>39.9 kg/m2 morbidly obese. Primary outcomes were long-term all-cause mortality and freedom from reintervention. Secondary outcome was aneurysm sac regression (defined as a reduction in sac diameter of 5 mm or more). Kaplan-Meier survival estimates and mixed model analysis of variance were used. RESULTS: The study included 515 patients (83% males, mean age 77 ± 8 years) with a mean follow-up of 3.8 ± 2.8 years. In terms of weight class, 2.1% (n = 11) were underweight, 32.4% (167) were NW, 41.6% (n = 214) were OW, 21.2% (n = 109) were obese, and 2.7% (n = 14) were morbidly obese. Obese patients were younger (mean difference -5.0 years) but had a higher prevalence of diabetes mellitus (33.3% vs. 10.6% for NW) and dyslipidemia (82.4% vs. 60.9% for NW). Obese patients had similar freedom from all-cause mortality (88%) compared to OW (78%) and NW (81%) patients. The same findings were evident for freedom from reintervention where obese (79%) was similar to OW (76%) and NW (79%). At a mean follow-up of 5.1 ± 0.4 years, sac regression was observed similarly across weight classes at 49.6%, 50.6%, and 51.8% for NW, OW, and obese, respectively (P = 0.501). There was a significant difference in mean AAA diameter pre- and post-EVAR [F(2,318) = 24.37, P < 0.001] across weight classes. NW [mean reduction 4.8 mm (2.0-7.6 mm, P < 0.001)], OW [mean reduction 3.9 mm (1.5-6.3 mm, P < 0.001)], and obese [mean reduction 5.7 mm (2.3-9.1 mm, P < 0.001)] achieved similar reductions. CONCLUSIONS: Obesity was not associated with increased mortality or reintervention in patients undergoing EVAR. Obese patients achieved similar rates of sac regression on imaging follow-up.

A systematic review and meta-analysis of the effect of obesity on patients undergoing lower extremity revascularization.

OBJECTIVE: In the present review, we assessed the effect of obesity on clinical outcomes for patients with peripheral arterial disease who had undergone endovascular or open lower extremity revascularization surgery. METHODS: A systematic search strategy of MEDLINE, EMBASE, CINAHL, Web of Science, and Cochrane Library was conducted. The included studies had compared obese and nonobese cohorts with peripheral arterial disease who had undergone endovascular or open lower extremity revascularization. The outcomes included mortality, major adverse cardiovascular events, major adverse limb events, surgical site infections, endovascular access site complications, and perioperative complications. RESULTS: Eight studies were included with 171,648 patients. The obese patients (body mass index ≥30 kg/m2) were more likely to be women, to have diabetes, and to have more cardiovascular comorbidities despite being younger. No association was found between obesity and peripheral arterial disease severity. Obesity was associated with an overall 22% decreased mortality risk after lower extremity revascularization (risk ratio [RR], 0.78; 95% confidence interval [CI], 0.71-0.85; P < .001; I2 = 0%; GRADE (grading of recommendations assessment, development, evaluation), very low quality). A subgroup analysis by intervention type showed similar findings (endovascular: RR, 0.79; 95% CI, 0.71-0.87; P < .001; I2 = 0%; open: RR, 0.70; 95% CI, 0.51-0.95; P = .024; I2 = 43%). Obesity was associated with a 14% decreased risk of major adverse cardiovascular events for open surgery only (RR, 0.86; 95% CI, 0.76-0.98; P = .021; I2 = 0%; GRADE, very low quality). Obesity was associated with an increased risk of surgical site infections pooled across intervention types (RR, 1.69; 95% CI, 1.34-2.14; P < .001; I2 = 78%; GRADE, very low quality). No association was found between obesity and major adverse limb events (RR, 1.02; 95% CI, 0.93-1.11; P = .73; I2 = 15%; GRADE, very low quality) or endovascular access site complications (RR, 1.11; 95% CI, 0.76-1.63; P = .58; I2 = 86%; GRADE, very low quality). Pooled perioperative complications did not differ between the obese and nonobese cohorts (RR, 1.04; 95% CI, 0.84-1.28; P = .73; I2 = 92%; GRADE, very low quality). CONCLUSIONS: Obesity was associated with reduced mortality risk with both endovascular and open surgery, although a reduction in major adverse cardiovascular events was only observed with open surgery. In addition, obese patients had an increased risk of surgical site infections. Obesity was not associated with major adverse limb events, endovascular access site complications, or perioperative complications. The GRADE quality of evidence was very low. The findings from the present review suggest a survival advantage for obese patients with peripheral arterial disease. Future studies could focus on prospectively investigating the effect of obesity on peripheral arterial disease outcomes. A nuanced evaluation of body mass index as a preoperative risk factor is warranted.

Severe inframalleolar disease is an independent predictor of adverse limb outcomes after endovascular revascularization in chronic limb-threatening ischemia.

OBJECTIVE: In the present study, we evaluated the effects of inframalleolar (IM) disease on the occurrence of major adverse limb events (MALE) in patients undergoing endovascular revascularization for chronic limb-threatening ischemia (CLTI). METHODS: Patients who had undergone endovascular revascularization for CLTI between January 2015 and December 2019 at two university-affiliated hospitals were reviewed retrospectively. Patients with severe IM disease (pedal score of 2) were compared with those with mild to moderate IM disease (score of 0 or 1) using the Global Vascular Guidelines. The primary outcome was MALE (open revascularization, acute leg ischemia, major amputation). The secondary outcomes were mortality, reintervention, major adverse cardiac events, and perioperative complications ≤30 days after endovascular revascularization, primary limb-based patency, and the occurrence of any limb event (defined as any amputation, acute leg ischemia, or open revascularization). Kaplan-Meier estimates were used to compare the primary outcome, and the Cox proportion hazard model was used to assess the effects of IM disease. RESULTS: The study included 167 limbs in 149 patients (36% female; mean age, 74 ± 12 years). Severe IM disease was identified in 71 limbs (43%). No differences were found in the baseline characteristics, except for a higher prevalence of dyslipidemia in the patients with severe IM disease (66% vs 43%; P = .003). Most patients in both groups had had a WIfI (Wound, Ischemia, foot Infection) score of 4 (severe IM disease, 64%; vs mild to moderate IM disease, 57%; P = .462) and GLASS (global limb anatomic severity scale) III anatomy (severe IM disease, 54%; vs mild to moderate IM disease, 48%; P = .752). The Kaplan-Meier estimates showed that severe IM disease was associated with lower freedom from MALE (69% vs 82%; P = .026). The Cox proportion hazard regression model showed that severe IM disease was an independent predictor of increased MALE and amputation risk (hazard ratio, 1.715; 95% confidence interval, 1.015-2.896; P = .044) after adjusting for covariates. During follow-up, patients with severe IM disease had had mortality (27% vs 31%; P = .567) and reintervention (42% vs 38%; P = .608) similar to those for patients with mild to moderate IM disease. Primary limb-based patency was also similar (79% vs 84%; P = .593) at a mean follow-up of 3.8 ± 0.8 years. CONCLUSIONS: Severe IM disease was prevalent in 43% of limbs that had undergone endovascular revascularization for CLTI and was associated with lower freedom from MALE. Severe IM disease also independently increased the hazard of adverse limb outcomes and amputations in patients with CLTI by >70%, highlighting its importance as a measure of foot perfusion.

Feasibility and Cost Analysis of Ambulatory Endovascular Aneurysm Repair.

PURPOSE: We sought to compare the costs of ambulatory endovascular aneurysm repair (a-EVAR) and inpatient EVAR (i-EVAR) at up to 1-year of follow-up. MATERIALS AND METHODS: A retrospective cohort study of consecutive patients undergoing elective EVAR between April 2016 and December 2018 at two academic centers. Patients planned for a-EVAR were compared with i-EVAR. Costs at 30 days and 1 year were extracted. These included operating room (OR) use, bed occupancy, laboratory and imaging, emergency department (ED) visits, readmissions, and reinterventions. Baseline characteristics were compared. Multiple regression model was used to identify predictors of increased EVAR costs. Repeated measures analysis of variance (ANOVA) was used to compare cost differences at 30 days and 1 year via an intention-to-treat analysis. Bonferroni post hoc test compared between-group differences. A p value<0.05 was considered statistically significant. RESULTS: One hundred seventy patients were included. Most underwent percutaneous EVAR (>94%) under spinal anesthesia (>84%). Ambulatory endovascular aneurysm repair was successful in 84% (84/100). Ambulatory endovascular aneurysm repair patients (76±8 years) were younger than i-EVAR (78±9 years). They also had a smaller mean aneurysm diameter (56±6 mm) compared with i-EVAR (59±6 mm). Emergency department visits, readmissions, and reinterventions were similar up to 1 year (all p=NS). Ambulatory endovascular aneurysm repair costs showed a non-statistically significant reduction in total costs at 30 days and 1 year by 27% and 21%, respectively. Patients younger than 85 years and males had a 30-day cost reduction by 34% (p=0.027) and 33% (p=0.035), respectively with a-EVAR. CONCLUSIONS: Same-day discharge is feasible and successful in selected patients. Patients younger than 85 years and males have a short-term cost benefit with EVAR done in the ambulatory setting without increased complications or reinterventions. CLINICAL IMPACT: This study shows the overall safety of ambulatory EVAR with proper patient selection. These patient had similar post-intervention complications to inpatients. Same day discharge also resulted in short-term reduction in costs in male patients and patients younger than 85 years.

Comorbid Depression is Associated with Increased Major Adverse Limb Events in Peripheral Arterial Disease: A Systematic Review and Meta-analysis.

OBJECTIVE: Depression is a significant risk factor for death in coronary artery disease. Conversely, the research surrounding depression and peripheral arterial disease is limited. This review aimed to systematically evaluate the available literature on the impact of comorbid depression on adverse outcomes in peripheral arterial disease. DATA SOURCES: A systematic review and meta-analysis were performed using the following databases MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane Library from inception until July 2021. REVIEW METHODS: Included studies compared depressed and non-depressed patients with peripheral arterial disease. The outcomes included death, major adverse cardiovascular events, and major adverse limb events. RESULTS: A total of 9 297 articles were searched. Of these, seven studies were identified. Depressed patients were more likely to be women, diabetic, have a history of smoking, and have chronic limb threatening ischaemia, despite being younger than non-depressed patients. There was a 20% increase in major adverse limb events in depressed patients (RR 1.20, 95% CI 1.11 - 1.31, z = 3.9, p < .001, GRADE strength: very low) but no increased risk of death (RR 1.03, 95% CI 0.72 - 1.40, z = 0.06, p = .95, GRADE strength: very low) or major adverse cardiovascular events (RR 1.16, 95% CI 0.67 - 2.01, z = 0.54, p = .59, GRADE strength: very low). A follow up meta-regression of various comorbidities and demographic variables did not demonstrate a significant contribution to the observed risk ratio for major adverse limb events. CONCLUSION: Depression was reported in 13% of patients with peripheral arterial disease, associated with more medical comorbidity, and a 20% increased risk of major adverse limb events. Although the strength of this evidence is very low, the current state of the literature remains limited. Future studies should prospectively assess the impact of depression and its relationship to medical comorbidities and high risk health behaviours.

Outcomes of endovascular treatment of patients with intermittent claudication due to femoropopliteal disease.

OBJECTIVE: Our objective was to evaluate the outcomes of endovascular treatment in patients with moderate and severe claudication due to femoropopliteal disease, that is, disease of the superficial femoral and popliteal arteries. METHODS: A retrospective review of all patients with moderate and severe claudication (Rutherford 2 and 3) undergoing endovascular treatment for FP disease between January 2012 and December 2017 at two university-affiliated hospitals was performed. All procedures were performed by vascular surgeons. Primary outcomes were mortality, freedom from reintervention, major adverse limb events defined as major amputations, open surgical revascularization, or progression to chronic limb-threatening ischemia (CLTI) at 30 days, 1 year, 2 years, and last follow-up. Unadjusted odds ratios were calculated to identify variables associated with adverse outcomes, and Kaplan-Meier survival curves were used to determine mortality and freedom from reintervention. RESULTS: Eighty-five limbs in 74 patients were identified on review. Mean age was 69.6 ± 9.8 years and 74.3% were males. At a median follow-up of 49.0 ± 25.5 months, all-cause mortality rate was 8.1% (6 patients) with 16.7% being due to cardiovascular causes. Reintervention rates were 1.2%, 16.5%, and 21.2% at 30 days, 1 year, and 2 years, respectively. Major adverse limb events occurred in 3 patients and rates were 0%, 1.2%, and 2.4% at 30 days, 1 year, and 2 years, respectively. Progression to CLTI was 0%, 1.2%, and 1.2% at 30 days, 1 year, and 2 years, respectively. Claudication had improved or resolved in 55.6% (n = 34 patients), stable in 38.9% (n = 21 patients), and worse in 5.6% (n = 3 patients) Age ≥ 70 years (OR = 4.09 (1.14-14.66), p = 0.027), TASCII A lesion (OR = 4.67 (1.14-19.17), p = 0.025), and presence of 3-vessel runoff (OR = 3.70 (1.18-11.59), p = 0.022) predicted symptoms' improvement. TASCII A lesions were less likely to require reintervention (OR = 0.23 (0.06-0.86), p = 0.020). Reintervention within 1 year (OR = 11.67 (0.98-138.94), p = 0.017), reintervention with a stent (OR = 14.40 (1.19-173.67), p = 0.008) and more than one reintervention (OR = 39.00 (2.89-526.28), p < 0.001) predicted major adverse limb events. CONCLUSIONS: Careful patient selection is important when planning endovascular treatment in patients with intermittent claudication and FP disease. This could result in symptomatic improvement in more than half of the patients. Adverse outcomes such as major adverse limb events, progression to CLTI, and amputations occur at low rates.

A systematic review and meta-analysis evaluating the impact of obesity on outcomes of abdominal aortic aneurysm treatment.

OBJECTIVE: We sought to evaluate the impact of obesity on perioperative mortality and complication rates in patients undergoing endovascular aortic repair (EVAR) and open surgical repair (OSR) for abdominal aortic aneurysms. METHODS: A systematic review of all studies reporting abdominal aortic aneurysm treatment perioperative (30-day) outcomes in obese patients (body mass index ≥30 kg/m2). The primary outcome was 30-day mortality. Secondary outcomes included cardiac complications, respiratory complications, wound complication, renal complications, and neurological complications at 30 days. These outcomes were pooled for meta-analysis. Analysis first compared obese vs nonobese patients undergoing EVAR and OSR then compared EVAR with OSR in obese patients. RESULTS: We identified seven observational studies with 14,971 patients (11,743 EVAR, 3228 OSR). Obese patients undergoing EVAR had lower 30-day mortality (1.5%) compared with nonobese patients (2.2%) (odds ratio [OR], 0.69; 95% confidence interval [CI], 0.50-0.96; P = .03; I2 = 0%; Grade of evidence: low). In OSR, obese patients (5.0%) had similar 30-day mortality to nonobese patients (5.7%) (OR, 0.92; 95% CI, 0.70-1.20; P = .54; I2 = 0%; Grade of evidence: low). Wound complications were higher in obese patients undergoing OSR (OR, 2.30; 95% CI, 1.74-3.06; P < .001; I2 = 0%; Grade of evidence: low). EVAR was associated with a lower 30-day mortality (1.5%) compared with OSR (5.0%) in obese patients (OR, 0.23; 95% CI, 0.12-0.46; P < .001; I2 = 38%; Grade of evidence: low). Cardiac, respiratory, wound, renal, and neurological complications were also reduced in EVAR. CONCLUSIONS: Obese patients have lower 30-day mortality in EVAR compared with nonobese patients. In OSR, obese patients had similar 30-day mortality but higher wound complications compared with nonobese patients. Obese patients otherwise have similar cardiopulmonary complication rates compared with nonobese patients in both EVAR and OSR. EVAR offers lower 30-day mortality and morbidity compared with OSR in obese patients. This study suggests that EVAR is superior to OSR in obese patients.

Hybrid Repair of a Thoraco-abdominal Aortic Aneurysm Associated with Loeys-Dietz Syndrome.

INTRODUCTION: Loeys-Dietz syndrome (LDS) is a genetic syndrome caused by mutations in transforming growth factor beta receptors (TGFBR) 1 and 2. It can manifest with craniofacial, musculoskeletal, cognitive abnormalities, and vascular pathologies including early onset aortic root aneurysms, extensive aortic dissections, and TAAA. Open repair is considered the gold standard treatment but carries morbidity risks, especially in patients with multiple previous aortic procedures. Endovascular treatment is associated with treatment failure when used in the native aorta, because of inherent wall weakness precluding seal. This case report adds to the available literature on hybrid treatment of LDS associated aortic pathologies. REPORT: This is the report of staged hybrid TAAA treatment in a 24 year old male patient with multiple previous aortic procedures via sternotomy and thoracotomy. Retrograde infrarenal aortic visceral debranching was performed using 14 mm by 7 mm bifurcated Dacron grafts. These emerged from the limbs of an 18 mm by 9 mm bifurcated Dacron graft in an aortobi-iliac reconstruction. This was followed by staged thoracic endovascular aortic repair (TEVAR) seven days later using three endografts (26 mm-22 mm × 150 mm distal, 30 mm × 200 mm bridging, then 32 mm × 100 mm proximal). The endograft landed in an old thoracic aortic graft proximally and the new infrarenal aortic graft distally. Follow up at 11 months showed patency and no sac expansion. CONCLUSION: Hybrid TAAA repair was a valid treatment option in this patient with LDS and multiple previous aortic procedures. It minimised the morbidity of revision surgery and mitigated potential treatment failure by achieving an endovascular seal in surgical grafts. Short term surveillance showed no complications. Limitations to making recommendations include lack of long term follow up.

Chronic Blunt Traumatic Thoracic Aortic Injuries: Report of three cases from Oman.

Blunt thoracic aortic injuries are potentially lethal. Those who survive may form an organised haematoma in the periadventitial space resulting in a pseudoaneurysm, which may be identified incidentally decades later. While the role of thoracic endovascular aortic repair (TEVAR) in acute settings has been established, its role in chronic cases is yet to be defined. We report three cases that were diagnosed incidentally six, nine and 18 years after the injury. Two were managed by TEVAR while the third declined intervention and is on annual follow-up. Patients with asymptomatic and stable pseudoaneurysms of the descending thoracic aorta should be offered surveillance versus TEVAR because the risk of rupture is not negligible, whilst taking into account the patient's level of physical activity. These three cases highlight the importance of early diagnosis of aortic injuries in blunt trauma and its grading.

Evolution of Plasmodium falciparum drug resistance genes following artemisinin combination therapy in Sudan.

BACKGROUND: Malaria control efforts in Sudan rely heavily on case management. In 2004, health authorities adopted artemisinin-based combination therapies (ACTs) for the treatment of uncomplicated malaria. However, some recent surveys have reported ACT failure and a prevalent irrational malaria treatment practice. Here we examine whether the widespread use of ACT and failure to adhere to national guidelines have led to the evolution of drug resistance genes. METHODS: We genotyped known drug resistance markers (Pfcrt, Pfmdr-1, Pfdhfr, Pfdhps, Pfk13 propeller) and their flanking microsatellites among Plasmodium falciparum isolates obtained between 2009 and 2016 in different geographical regions in Sudan. Data were then compared with published findings pre-ACT (1992-2003). RESULTS: A high prevalence of Pfcrt76T, Pfmdr-1-86Y, Pfdhfr51I, Pfdhfr108N, Pfdhps37G was observed in all regions, while no Pfk13 mutations were detected. Compared with pre-ACT data, Pfcrt-76T and Pfmdr-1-86Y have decayed, while Pfdhfr-51I, Pfdhfr-108N and Pfdhps-437G strengthened. Haplotypes Pfcrt-CVIET, Pfmdr-1-NFSND/YFSND, Pfdhfr-ICNI and Pfdhps-SGKAA predominated in all sites. Microsatellites flanking drug resistance genes showed lower diversity than neutral ones, signifying high ACT pressure/selection. CONCLUSIONS: Evaluation of P. falciparum drug resistance genes in Sudan matches the drug deployment pattern. Regular monitoring of these genes, coupled with clinical response, should be considered to combat the spread of ACT resistance.

Outcomes of Early versus Delayed Endovascular Repair of Blunt Traumatic Aortic Injuries.

OBJECTIVES: Thoracic endovascular aortic repair (TEVAR) has surpassed open surgical repair in the management of blunt traumatic aortic injuries (BTAIs) over the past two decades. It is a less morbid procedure associated with lower mortality. We sought to determine the outcomes of early versus delayed TEVAR of BTAI in our population. METHODS: We conducted a retrospective analysis of a prospectively collected registry that looked at patients presenting with an image-proven diagnosis of BTAI at three tertiary health care facilities in Muscat, Oman. Forty consecutive patients were identified between January 2012 and July 2017, of which four were excluded for incomplete data. The remaining 36 patients were divided based on the timing of repair into early (< 7 days) or delayed (3 7 days) repair. In both cohorts, variables analyzed included patient demographics, mechanism of injury, injury severity score, need for blood products transfusion, use of anti-impulse medications, anticoagulation, intensive care unit (ICU) stay, and total hospital stay. Primary endpoints included: in-hospital mortality, TEVAR-related morbidity, and the need for reintervention. RESULTS: Our study subjects were young with a mean age of 33.5±14.8 and 29.9±11.0 years in the early and delayed repair cohorts, respectively. Motor vehicle collisions accounted for the majority of cases (82.6% and 76.9% in early and delayed repair, respectively). Thoracic injuries were the most commonly associated injuries in both early and delayed repair cohorts. Compared to early repair, the delayed repair cohort had a higher incidence of exploratory laparotomies, but the difference was not statistically significant (p = 0.161). There were four incidences of cerebrovascular accidents (CVAs) post-TEVAR; three in the early repair cohort and one in the delayed repair cohort (p = 1.000). There was no statistically significant correlation between left subclavian total or partial coverage and the incidence of CVA (p = 0.220) and type 1 (p = 0.466) or type 2 endoleak (p = 0.102). The early repair cohort had a longer but not statistically significant ICU stay (7.8±6.8 vs. 5.3±10.7, p = 0.386). Prolonged ICU stay was associated with more blood transfusion requirement (p < 0.001), and higher respiratory (p = 0.010) and gastrointestinal complications (p = 0.026). CONCLUSIONS: The short-term outcomes for TEVAR of BTAI continue to show its feasibility in managing BTAI in severely injured patients. There was no clear statistical significance in mortality and morbidity comparing early versus delayed repair. However, our experience is based on a small sample size and short median follow-up but provides a good platform for further analysis.

Distribution of Trauma Care Facilities in Oman in Relation to High-Incidence Road Traffic Injury Sites: Pilot study.

OBJECTIVES: Road traffic injuries (RTIs) are considered a major public health problem worldwide. In Oman, high numbers of RTIs and RTI-related deaths are frequently registered. This study aimed to evaluate the distribution of trauma care facilities in Oman with regards to their proximity to RTI-prevalent areas. METHODS: This descriptive pilot study analysed RTI data recorded in the national Royal Oman Police registry from January to December 2014. The distribution of trauma care facilities was analysed by calculating distances between areas of peak RTI incidence and the closest trauma centre using Google Earth and Google Maps software (Google Inc., Googleplex, Mountain View, California, USA). RESULTS: A total of 32 trauma care facilities were identified. Four facilities (12.5%) were categorised as class V trauma centres. Of the facilities in Muscat, 42.9% were ranked as class IV or V. There were no class IV or V facilities in Musandam, Al-Wusta or Al-Buraimi. General surgery, orthopaedic surgery and neurosurgery services were available in 68.8%, 59.3% and 12.5% of the centres, respectively. Emergency services were available in 75.0% of the facilities. Intensive care units were available in 11 facilities, with four located in Muscat. The mean distance between a RTI hotspot and the nearest trauma care facility was 34.7 km; however, the mean distance to the nearest class IV or V facility was 83.3 km. CONCLUSION: The distribution and quality of trauma care facilities in Oman needs modification. It is recommended that certain centres upgrade their levels of trauma care in order to reduce RTI-associated morbidity and mortality in Oman.

Missed Gastric Injuries in Blunt Abdominal Trauma: Case report with review of literature.

Hollow viscus injuries of the digestive tract are an uncommon occurrence in blunt abdominal trauma. We report a 39-year-old male who was hit by a vehicle as a pedestrian and admitted to the Sultan Qaboos University Hospital, Muscat, Oman, in 2015. He underwent an exploratory laparotomy which revealed injuries to the distal stomach, liver and descending colon. Postoperatively, the patient was febrile, tachycardic and hypotensive. Abdominal examination revealed distention and tenderness. The next day, a repeat laparotomy identified a gastric injury which had not been diagnosed during the initial laparotomy. Although the defect was repaired, the patient subsequently died as a result of multiorgan failure. Missed gastric injuries are rare and are associated with a grave prognosis, particularly for trauma patients. Delays in diagnosis, in addition to associated injuries, contribute to a high mortality rate.

Use of Prophylactic Inferior Vena Cava Filters in Trauma.

Venous thromboembolisms, specifically pulmonary embolisms (PEs), represent a significant burden on healthcare systems worldwide, particularly within the setting of trauma. According to the literature, PEs are the most common cause of in-hospital death; however, this condition can be prevented with a variety of prophylactic and therapeutic measures. This article aimed to examine current evidence on the use, indications for prophylaxis, outcomes and complications of prophylactic inferior vena cava filters in trauma patients.