A hybrid endovascular and open approach to rare thyrocervical trunk and subclavian pseudoaneurysms complicated by embolic brachial artery occlusion.

Subclavian and thyrocervical trunk pseudoaneurysms are rare pathologies and even more so when they occur simultaneously. Treatment of these vascular injuries can be done endovascularly or with open surgery. We present a novel two-stage, hybrid open and endovascular approach to the management of a healthy 41-year-old man with no personal or family history of connective tissue disorders, who presented with subclavian branch and thyrocervical trunk pseudoaneurysms complicated by brachial artery occlusion. The pseudoaneurysms were treated with microvascular plug deployment, followed by subclavian artery covered stenting, with treatment of the brachial occlusion via open thrombectomy with patch angioplasty. The patient recovered without any complications.

Impact of Patient and Procedural Factors on Outcomes Following Mesenteric Bypass.

BACKGROUND: Mesenteric bypass (MB) for patients with acute (AMI) and chronic mesenteric ischemia (CMI) is associated with cardiovascular (CV) and pulmonary morbidity. METHODS: Patients with AMI and CMI from 2008 to 2019 were identified to determine independent predictors of CV (cardiac arrest, MI, DVT, and stroke) and pulmonary (pneumonia and ventilator time>48 h) morbidities in patients undergoing MB. RESULTS: 377 patients were identified. Patients with AMI had higher rates of preoperative SIRS/sepsis (28 vs 12%, P < .0001), were more likely to be ASA class 4/5 (55 vs 42%, P = .005), were more likely to require bowel resection (19 vs 3%, P < .0001), and were more likely to have vein utilized as their bypass conduit (30 vs 14%, P < .0001). There were no differences in use of aortic or iliac inflow (P = .707) nor in return to the OR (24 vs 19%, P = .282). Both postoperative sepsis (12 vs 2.6%, P = .003) and mortality (31.4% vs 9.8%, P < .0001) were significantly increased in patients with AMI. After adjusting for both patient and procedural factors, multivariable logistic regression (MLR) identified international normalized ratio (INR) (OR 3.16; 95% CI 1.56-6.40, P = .001) and chronic heart failure (CHF) (OR 5.88; 95% CI 1.15-29.97, P = .033) to be independent predictors of pulmonary morbidity, while preoperative sepsis (OR 1.96; 95% CI 1.45-2.66, P < .0001) alone was predictive of CV morbidity in all patients undergoing MB. DISCUSSION: Mesenteric bypass for mesenteric ischemia leads to high rates of morbidity and mortality, whether done in an acute or chronic setting. Preoperative sepsis, independent of AMI or CMI, predicts CV morbidity, regardless of bypass configuration or conduit, while elevated INR or underlying CHF carries a higher risk of pulmonary morbidity.

Risk Factors for Acute Renal Failure After Endovascular Aneurysm Repair.

BACKGROUND: Acute kidney injury (AKI) after endovascular aortic aneurysm repair (EVAR) is uncommon though carries significant morbidity. Procedural risk factors are not well established for acute renal failure (ARF) that requires initiation of dialysis. The goal of this study was to examine the impact of ARF on patients undergoing EVAR and identify risk factors for ARF using a large, national dataset. METHODS: Patients undergoing EVAR were identified from the National Surgical Quality Improvement Program (NSQIP) database over 9 years, ending in 2019. Demographics, indication for repair, comorbidities, procedural details, complications, hospital and ICU LOS, and mortality were recorded. Patients were stratified by presence of ARF and compared. Patients were further stratified by indication for EVAR and presence of ARF. Multivariable logistic regression (MLR) analysis was performed to determine the independent predictors of ARF. RESULTS: 18 347 patients were identified. Of these 234 (1.3%) developed ARF requiring dialysis. Mortality (40 vs 1.8%, P < .0001), ICU LOS (5 vs 0 days, P < .0001), and hospital LOS (11 vs 2 days, P < .0001) were all significantly increased in patients with ARF. Multivariable logistic regression identified increasing diameter, creatinine, operative time, preoperative transfusions, ASA class, emergent repair, female gender, and juxtarenal/suprarenal proximal landing zone as predictors of ARF. CONCLUSIONS: ARF after EVAR causes significant morbidity, prolongs hospitalizations, and increases mortality rates. Those patients at risk of ARF after EVAR should be closely monitored to reduce both morbidity and mortality.

Role of Endovascular Stenting in Patients with Traumatic Iliac Artery Injury.

BACKGROUND: Common and external iliac artery injuries (IAI) portend significant morbidity and mortality. The goal of this study was to examine the impact of mechanism of injury and type of repair on outcomes and identify the optimal repair for patients with traumatic IAI using a large, national dataset. STUDY DESIGN: Patients undergoing operative repair for IAI were identified from the Trauma Quality Improvement Program database during a 5-year timespan, ending in 2019. Age, sex, race, severity of injury, severity of shock, type of iliac repair (open or endovascular), mechanism, morbidity and mortality were recorded. Patients with IAI were stratified by both type of repair and mechanism and compared. Multivariable logistic regression analysis was used to identify independent predictors of mortality. RESULTS: Operative IAI was identified in 507 patients. Of these injuries, 309 (61%) were penetrating and 346 (68.2%) involved the external iliac artery. The majority of patients were male (82%) with a median age and ISS of 31 and 20, respectively. Endovascular repair was performed in 31% of cases. For patients with penetrating injuries, the type of repair impacted neither morbidity nor mortality. For blunt-injured patients, endovascular repair was associated with lower morbidity (29.3% vs 41.3%; p = 0.082) and significantly reduced mortality (14.6% vs 26.7%; p = 0.037) compared with the open-repair approach. Multivariable logistic regression identified endovascular repair as the only modifiable risk factor associated with decreased mortality (odds ratio 0.34; 95% CI 0.15 to 0.79; p = 0.0116). CONCLUSIONS: Traumatic IAI causes significant morbidity and mortality. Endovascular repair was identified as the only modifiable predictor of decreased mortality in blunt-injured patients with traumatic IAI. Therefore, for select patients with blunt IAIs, an endovascular repair should be the preferred approach.

In for a Penny, in for a Pound: Obesity weighs heavily on both cost and outcome in trauma.

BACKGROUND: The current literature offers mixed conclusions regarding the effect of increased body mass index (BMI) on outcomes after trauma laparotomy. This study evaluated the impact of obesity on outcomes and cost for patients undergoing trauma laparotomy at a level 1 trauma center. STUDY DESIGN: Data on patients requiring trauma laparotomy in 2016 were prospectively collected and patients were stratified by BMI. Statistical analyses were used to determine variables significantly associated with patient morbidity and length of stay. RESULTS: 313 patients underwent trauma laparotomy: 225 non-obese, 69 obese, and 19 morbidly obese. Obese and morbidly obese patients had longer ICU and hospital lengths of stay (LOS), more ventilator days, larger hospital costs, and higher morbidity compared to non-obese patients. Obesity was an independent predictor for patient morbidity, ICU, and hospital LOS. CONCLUSIONS: Morbidity and length of stay increased with worsening obesity after trauma laparotomy, contributing to rising hospital costs.

Delayed Endovascular Repair With Procedural Anticoagulation: A Safe Strategy for Blunt Aortic Injury.

BACKGROUND: Blunt aortic injury (BAI) and traumatic brain injury (TBI) are the leading causes of death after blunt trauma. The purposes of this study were to identify predictors of mortality for BAI and to examine the impact of procedural heparinization during thoracic endovascular aortic repair (TEVAR) on neurologic outcomes in patients with BAI/TBI. METHODS: Patients with BAI were identified over an 8 year period. Age, gender, severity of injury and shock, time to TEVAR, morbidity, and mortality were recorded and compared. Multivariable logistic regression (MLR) was performed to determine independent predictors of mortality. Youden's index determined optimal time to TEVAR. RESULTS: A total of 129 patients were identified. The majority (74%) were male with a median age and injury severity score (ISS) of 40 years and 29, respectively. Of these, 26 (20%) had a concomitant TBI. Patients with BAI/TBI had higher injury burden at presentation (ISS 37 vs. 29, P = 0.002; Glasgow Coma Scale [GCS] 6 vs. 15, P < 0.0001), underwent fewer TEVAR procedures (31 vs. 53%, P = 0.039), and suffered increased mortality (39 vs. 16%, P = 0.009). All TEVARs had procedural anticoagulation, including patients with TBI, without change in neurologic function. The optimal time to TEVAR was 14.8 hr. Mortality increased in TEVAR patients before 14.8 hr (8.7 vs. 0%, P = 0.210). MLR identified TEVAR as the only modifiable factor that reduced mortality (odds ratio 0.11; 95% confidence interval 0.03-0.45, P = 0.002). CONCLUSIONS: TEVAR use was identified as the only modifiable predictor of reduced mortality in patients with BAI. Delayed TEVAR with the use of procedural heparin provides a safe option regardless of TBI with improved survival and no difference in discharge neurologic function.

Impact of Endovascular Stenting on Outcomes in Patients with Traumatic Subclavian Artery Injury.

BACKGROUND: Traumatic subclavian artery injury (SAI) remains uncommon but can lead to significant morbidity and mortality. Although open and endovascular repair offer excellent limb salvage rates, their role in blunt and penetrating injuries is not well defined. The goal of this study was to examine the effect of mechanism of injury and type of repair on outcomes in patients with traumatic SAI. STUDY DESIGN: Patients undergoing procedures for traumatic SAI were identified from the Trauma Quality Improvement Program database between 2015 and 2018. Demographics, severity of injury and shock, type of subclavian repair (open vs endovascular), morbidity, and mortality were recorded. Patients with SAI were stratified by mechanism and type of repair and compared. Multivariable logistic regression (MLR) analysis was performed to determine independent predictors of mortality. RESULTS: Seven hundred thirty-seven patients undergoing procedures for SAI were identified. Of these, 39% were penetrating. The majority were male (80%) with a median age and Injury Severity Score (ISS) of 37 and 21, respectively. 58% of patients were managed endovascularly. For patients with blunt injury, the type of repair affected neither morbidity (25% vs 19%, p = 0.116) nor mortality (11% vs 10%, p = 0.70). For patients with penetrating injuries, endovascular repair had significantly lower morbidity (12% vs 22%, p = 0.028) and mortality (6% vs 21%, p = 0.001). MLR identified endovascular repair as the only modifiable risk factor associated with reduced mortality (odds ratio, 0.35; 95% confidence interval, 0.14 to 0.87, p = 0.02). CONCLUSIONS: SAI results in significant morbidity and mortality regardless of mechanism. Although the type of repair did not affect mortality in patients with blunt injury, endovascular repair was identified as the only modifiable predictor of reduced mortality in patients with penetrating injuries.

Pediatric peripheral vascular injuries and associated orthopedic considerations.

Pediatric peripheral vascular trauma is a rare but highly morbid injury in children and is frequently associated with concomitant orthopedic injuries. These children require multidisciplinary care by pediatric, vascular, and orthopedic surgery. In this review, we describe elements of the complex care required for children with peripheral vascular trauma.