Successful Revascularization of Aortic Arch in a 39-Year-Old Blunt Trauma Patient with Acute Diffuse Axonal Injury without the Use of Systemic Anticoagulation.

Blunt traumatic aortic injury is the second leading cause of death in trauma patients aged 4-34 years. Of the patients who are able to receive treatment, mortality rates as high as 40% have been reported. Endovascular repair options have allowed for more expeditious repairs with reduced iatrogenic trauma; however, when the injury involves the ascending aorta or arch, current endografts lack fenestrations needed for cerebral blood flow. Traditionally, on pump, cardiopulmonary bypass with systemic anticoagulation has been used to repair these injuries. In this paper, we describe a unique case of repairing a large traumatic aortic arch pseudoaneurysm in the setting of which systemic anticoagulation is contraindicated. The patient is a 39-year-old otherwise healthy Hispanic male who presented to Ryder Trauma Center in Miami, Florida, following a motor vehicle collision and found to have multiple intracranial hemorrhages and a large aortic pseudoaneurysm of the distal ascending aorta. In lieu of standard cardiopulmonary bypass, a hybrid approach was utilized. Cranial blood flow was maintained using a temporary extra-anatomical left femoral to bilateral carotid bypass during endovascular coverage of the aortic arch. Aortic arch revascularization was then achieved by means of in situ laser fenestration of the innominate artery followed by a right-to-left carotid-carotid-subclavian bypass. This case demonstrates the viability of a hybrid vascular repair of a complex aortic disruption without the use of systemic anticoagulation in the setting of contraindicated or unknown risk of systemic anticoagulation. Further research is warranted on whether emergent traumatic cases with contraindications to anticoagulation can be performed in a similar fashion to safely reduce the morbidity and mortality associated with aortic disruptions.

The evidence for nonoperative management of visceral artery dissections: a single-center experience.

BACKGROUND: Spontaneous isolated visceral artery dissection is an uncommon condition encountered by clinicians. Presentation may vary from asymptomatic to acute intestinal ischemia, although a clear natural history has yet to be elucidated. No consensus exists on how best to manage these patients in the absence of true intestinal ischemia; however, much of the literature suggests that intervention is required. We present our institution's experience with 10 patients, both symptomatic and asymptomatic, all but 1 of whom was managed medically. METHODS: From September 2009 to August 2013, 10 patients presented to our institution with celiac or mesenteric artery dissection. We retrospectively reviewed these patients' clinical presentation, treatment, and follow-up. RESULTS: The mean age of the patients was 61.5 ± 10.3 (standard deviation [SD]) years (range, 41-77 years), and the mean follow-up period was 14.7 ± 11.6 (SD) months (range, 1-31 months). Four (40%) patients had abdominal pain and no ischemic changes of the bowel. There were 1 type I, 6 type II, 2 type III, and 1 type IV dissections according to Sakamoto classification. Treatments included observation without anticoagulation treatment in 8 patients (80%), anticoagulation treatment in 1 patient (10%), and endovascular stenting in 1 patient (10%) with unremitting abdominal pain. Anticoagulation was used in the 1 symptomatic patient with radiographic evidence of associated thrombus. The disease stabilized in all patients during follow-up. CONCLUSIONS: Most authors tend to advocate an endovascular or even operative repair for these processes. In our experience, most of these patients have a self-limited course of symptoms or their dissections are found incidentally. We believe that the results of conservative management in our cohort of patients support the conservative approach over the once recommended operative repair.

The effect of metallic tracheal stents on radiation dose in the airway and surrounding tissues.

BACKGROUND: Metallic airway stents are often used in the management of central airway malignancies. The presence of a metallic foreign body may affect radiation dose in tissue. We studied the effect of a metallic airway stent on radiation dose delivery in a phantom and an in vivo porcine model. METHODS: A metallic tracheal stent was fitted onto a support in a water phantom. Point dosimeters were positioned in the phantom around the support and the stent. Irradiation was then performed on a linear accelerator with and without the stent. Metallic tracheal stents were deployed in the trachea of three pigs. Dosimeters were implanted in the tissues near (Group 1) and away (Group 2) from the stent. The pigs were then irradiated, and the dose perturbation factor was calculated by comparing the actual dose detected by the dosimeters versus the planned dose. RESULTS: The difference in the dose detected by the dosimeters and the planned dose ranged from 1.8% to 6.1% for the phantom with the stent and 0%-5.3% for the phantom without the stent. These values were largely within the manufacturer's specified error of 5%. No significant difference was observed in the dose perturbation factor for Group 1 and Group 2 dosimeters (0.836 ± 0.058 versus 0.877 ± 0.088, P = 0.220) in all the three pigs. CONCLUSIONS: Metallic airway stents do not significantly affect radiation dose in the airway and surrounding tissues in a phantom and porcine model. Radiation treatment planning systems can account for the presence of the stent. External beam radiation can be delivered without concern for significant dose perturbation.