Late coronary artery injury following chemoradiotherapy for thymic carcinoma: a case report.

INTRODUCTION: Surgery remains the primary treatment modality for thymic carcinoma, with adjuvant radiotherapy being recommended to effectively mitigate local recurrence and metastasis rates subsequent to incomplete or complete resection. Chemoradiotherapy has the potential to induce coronary artery occlusion, thereby potentially impacting patients' long-term survival rates. The existing literature currently lacks comprehensive research on the lesion characteristics of coronary artery injury resulting from chemoradiotherapy. CASE PRESENTATION: The male patient, aged 55, was admitted to the hospital due to recurrent chest tightness and pain persisting for one week. Notably, the patient had previously undergone curative resection surgery for thymic carcinoma seven years ago. After the surgical procedure, the patient underwent a course of adjuvant chemotherapy comprising docetaxel and platinum. 11 months later, imaging examination diagnosed tumor recurrence, and concurrent chemoradiotherapy was administered at a total dose of 62 Gy/31F for planning gross target volume (PGTV) and 54 Gy/31F for planning target volume (PTV) with 2 cycles of paclitaxel and cisplatin. Re-admission of the patient occurred after a 7-year interval subsequent to the completion of concurrent chemoradiotherapy, leading to a subsequent diagnosis of acute non-ST segment elevation myocardial infarction. Following administration of antiplatelet, anticoagulant, and anti-myocardial ischemia therapy, coronary angiography revealed the presence of a bifurcation lesion at the distal end of the left main trunk. Intravascular ultrasound (IVUS) examination demonstrated significant negative remodeling of both the main trunk and its branches at the bifurcation site, characterized by minimal atherosclerotic plaque components. CONCLUSIONS: Chemoradiotherapy may induce damage to endothelial cells, resulting in an inflammatory response. Negative remodeling of blood vessels is likely to occur, primarily characterized by vasoconstriction but with less atherosclerotic plaque burden. Routine stent implantation in negatively remodeled areas may lead to vascular rupture, necessitating intravascular imaging examination.

Understanding large vessel perforation requiring treatment with covered stent implantation: A case series.

Large vessel perforation during coronary intervention is a rare but potentially fatal complication, often requiring implantation of a covered stent for resolution. While technology is improving, the long-term patency of covered stents is less than drug-eluting stents, and implantation of covered stents should be used sparingly. Large vessel perforations are complex and often the perforation inflow is not located at the site of extravasation seen on angiography. This can lead to geographic miss when implanting covered stents and necessitate the implantation of additional covered stents which increases the risk for short- and long-term complications. We present a case series to further investigate the anatomy and mechanism of large vessel perforations and guidance on effective covered stent implantation.

Peroneal artery injury potential due to different syndesmosis screw placement options: a simulation study with lower extremity computed tomography angiography.

INTRODUCTION: The aim of this study is to assess the risk of peroneal artery injury of hardware placement at the fixation of syndesmotic injuries. MATERIALS AND METHODS: The lower extremity computed tomography angiography was used to design the study. The syndesmosis screw placement range was simulated every 0.5 cm, from 0.5 to 5 cm proximal to the ankle joint. The screw axes were drawn as 20°, 30° or individual angle according to the femoral epicondylar axis. The proximity between the screw axis and the peroneal artery was measured in millimeters. Potential peroneal artery injury was noted if the distance between the peroneal artery to the axis of the simulated screw was within the outer shaft radius of the simulated screw. The Pearson chi-square test was used and a p-value < 0.05 was considered significant. RESULTS: The potential for injury to the peroneal artery increased as the syndesmosis screw level rose proximally from the ankle joint level or as the diameter of the syndesmosis screw increasds. In terms of syndesmosis screw trajection, the lowest risk of injury was observed with the syndesmosis screw angle of 20°. Simulations with a screw diameter of 3.5 mm exhibited the least potential for peroneal artery injury. CONCLUSION: Thanks to this radiological anatomy simulation study, we believe that we have increased the awareness of the peroneal artery potential in syndesmosis screw application. Each syndesmosis screw placement option may have different potential for injury to the peroneal artery. To decrease the peroneal artery injury potential, we recommend the followings. If individual syndesmosis screw angle trajection can be measured, place the screw 1.5 cm proximal to the ankle joint using a 3.5 mm screw shaft. If not, fix it with 30° trajection regardless of the screw diameter at the same level. If the most important issue is the peroneal artery circulation, use the screw level up to 1 cm proximal to the ankle joint regardless of the screw angle trajection and screw diameter.

Endovascular Treatment of Traumatic Vascular Injuries in the Head and Neck Region.

Background and Objectives: Traumatic vascular injuries of the head and neck pose significant treatment challenges due to the complex anatomy, diverse clinical presentation, and mostly emergent nature. Endovascular treatment increasingly complements traditional surgical approaches. This study aimed to report our 10-year experience in treating traumatic vascular injuries of the head and neck with endovascular therapy and to determine the effectiveness of endovascular treatment. Materials and Methods: A retrospective analysis of 21 patients treated for head and neck vascular injuries between May 2011 and April 2021 was performed. Patients' medical histories, clinical presentations, imaging findings, treatment materials, and clinical outcomes were reviewed. Treatments included stenting, coil embolization, and other endovascular techniques focused on hemostasis and preservation of the parent vessel. Results: The most common injuries involved the internal maxillary artery branches (n = 11), followed by the common or internal carotid artery (n = 6), vertebral artery (n = 3), and others. Endovascular treatment achieved successful hemostasis in all but one case. In five of six carotid artery injuries and two of three vertebral artery injuries, we achieved successful hemostasis while preserving the parent vessel using covered and bare stents, respectively. Conclusions: Endovascular therapy might be a useful treatment modality for traumatic vascular injuries in the head and neck region, offering efficacy, safety, and a minimally invasive approach.

Open versus endovascular repair of penetrating non-aortic arterial injuries: A systematic review and meta analysis.

BACKGROUND: Non-aortic arterial injuries are common and are associated with high morbidity and mortality. Historically, open surgical repair (OSR) was the conventional method of repair. With recent advancements in minimally invasive techniques, endovascular repair (ER) has gained popularity. We sought to compare outcomes in patients undergoing endovascular and open repairs of traumatic non-aortic penetrating arterial injuries. METHODS: A systematic review and meta-analysis was conducted using MEDLINE (OVID), Web of Science, Cochrane Library, and Scopus Database from January 1st, 1990, to March 20th, 2023. Titles and abstracts were screened, followed by full text review. Articles assessing clinically important outcomes between OSR and ER in penetrating arterial injuries were included. Exclusion criteria included blunt injuries, aortic injuries, pediatric populations, review articles, and non-English articles. Odds ratios (OR) and Cohen's d ratios were used to quantify differences in morbidity and mortality. RESULTS: A total of 3770 articles were identified, of which 8 met inclusion criteria and were included in the review. The articles comprised a total of 8369 patients of whom 90 % were male with a median age of 28 years. 85 % of patients were treated with OSR while 15 % underwent ER. With regards to injury characteristics, those who underwent ER were less likely to present with concurrent venous injuries (OR: 0.41; 95 %CI: 0.18, 0.94; p = 0.03). Regarding hospital outcomes, patients who underwent ER had a lower likelihood of in-hospital or 30-day mortality (OR: 0.72; 95 %CI: 0.55, 0.95; p = 0.02) and compartment syndrome (OR: 0.29, 95 %CI: 0.12, 0.71; p = 0.007). The overall risk of bias was moderate. CONCLUSION: Endovascular repair of non-aortic penetrating arterial injuries is increasingly common, however open repair remains the most common approach. Compared to ER, OSR was associated with higher odds of compartment syndrome and mortality. Further prospective research is warranted to determine the patient populations and injury patterns that most significantly benefit from an endovascular approach. LEVEL OF EVIDENCE: Level III, Systematic Reviews & Meta-Analyses.

Predictive Factors of Intestinal Ischaemia in Adhesive Small Bowel Obstruction.

OBJECTIVE: To identify the predictive factors of intestinal ischaemia in adhesive small bowel obstruction (ASBO) and develop an intestinal ischaemia risk score. STUDY DESIGN: Observational study. Place and Duration of the Study: Department of General Surgery, Shandong Provincial Qianfoshan Hospital, Jinan, Shandong, China, from January 2017 to February 2022. METHODOLOGY: ASBO was determined by findings at laparotomy. The assessment of small bowel's viability was conducted through surgical inspection and subsequent histological examination of the surgical specimen. Univariate and multivariate analyses were conducted to ascertain the risk factors associated with intestinal ischaemia. RESULTS: In total, 79 patients were included. Factors entered into multivariate analysis associated with intestinal ischaemia were; rebound tenderness (odds ratio (OR): 7.8, 95% confidence interval (CI):1.7-35.3; p=0.008), procalcitonin (PCT) >0.5 ng/mL (OR: 11.7, 95% CI: 2.3-58.1; p=0.003), and reduced bowel wall enhancement on computerised tomography (CT) scan (OR: 12.2, 95% CI:2.4-61.5; p=0.003). Among patients with 0, 1, 2, and 3 factors, the rate of intestinal ischaemia increased from 0% to 49%, 72%, and 100%, respectively. According to the number of risk factors, the area under the receiver operating characteristic curve for the determination of intestinal ischaemia was 0.848 (95% CI: 0.764-0.932). CONCLUSION: Rebound tenderness, PCT levels >0.5 ng/mL, and reduced bowel wall enhancement are risk factors of intestinal ischemic injury that require surgery within the context of ASBO. These factors need to be closely monitored that could assist clinicians in avoiding unnecessary laparotomies and selecting patients eligible for surgery. KEY WORDS: Intestinal obstruction, Ischaemia, Adhesions.

Long-term functional outcomes of upper extremity civilian vascular trauma.

OBJECTIVE: Civilian analyses of long-term outcomes of upper extremity vascular trauma (UEVT) are limited. Our goal was to evaluate the management of UEVT in the civilian trauma population and explore the long-term functional consequences. METHODS: A retrospective review and analysis was performed of patients with UEVT at an urban Level 1 trauma center (2001-2022). Management and long-term functional outcomes were analyzed. RESULTS: There were 150 patients with UEVT. Mean age was 34 years, and 85% were male. There were 42% Black and 27% White patients. Mechanism was penetrating in 79%, blunt in 20%, and multifactorial in 1%. Within penetrating trauma, mechanism was from firearms in 30% of cases. Of blunt injuries, 27% were secondary to falls, 13% motorcycle collisions, 13% motor vehicle collisions, and 3% crush injuries. Injuries were isolated arterial in 62%, isolated venous in 13%, and combined in 25% of cases. Isolated arterial injuries included brachial (34%), radial (27%), ulnar (27%), axillary (8%), and subclavian (4%). The majority of arterial injuries (92%) underwent open repair with autologous vein bypass (34%), followed by primary repair (32%), vein patch (6.6%), and prosthetic graft (3.3%). There were 23% that underwent fasciotomies, 68% of which were prophylactic. Two patients were managed with endovascular interventions; one underwent covered stent placement and the other embolization. Perioperative reintervention occurred in 12% of patients. Concomitant injuries included nerves (35%), bones (17%), and ligaments (16%). Intensive care unit admission was required in 45%, with mean intensive care unit length of stay 1.6 days. Mean hospital length of stay was 6.7 days. Major amputation and in-hospital mortality rates were 1.3% and 4.6% respectively. The majority (72%) had >6-month follow-up, with a median follow-up period of 197 days. Trauma readmissions occurred in 19%. Many patients experienced chronic pain (56%), as well as motor (54%) and sensory (61%) deficits. Additionally, 41% had difficulty with activities of daily living. Of previously employed patients (57%), 39% experienced a >6-month delay in returning to work. Most patients (82%) were discharged with opioids; of these, 16% were using opioids at 6 months. CONCLUSIONS: UEVT is associated with long-term functional impairments and opioid use. It is imperative to counsel patients prior to discharge and ensure appropriate follow-up and therapy.

Pediatric Vascular Surgery: A Review of Cases from a Dedicated Pediatric Vascular Surgery Clinic.

BACKGROUND: The experience in pediatric vascular diseases is limited in the United Kingdom and worldwide due to their rarity and variations in practice. We looked at types of cases presenting to a dedicated pediatric vascular clinic. METHODS: Medical records of children seen in a dedicated pediatric vascular clinic at a tertiary referral service between 2016 and 2022 were reviewed. These patients were either seen for the first time in that clinic or had their appointments as a follow-up after inpatient review or intervention while being under the care of pediatric teams in local hospitals. RESULTS: Fifty-five patients (34 males) were seen aged between 4 months and 17 years (mean 9.5 years). Common presentations were limb length discrepancy secondary to iatrogenic arterial occlusion, follow-up after bypass for trauma, lower limb swelling or discoloration, and varicose veins. Operative procedures included lower limb bypass, angioplasty, ligation of aneurysms, and varicose vein surgery. CONCLUSIONS: Pediatric vascular conditions are uncommon and therefore most vascular surgeons and trainees will have little exposure to such cases. Intervention is needed for arterial injury secondary to penetrating or iatrogenic trauma. A national registry is required for these rare cases to gain prospective data that can help build up more evidence for educational purposes and to establish guidelines.

Emergency Endovascular Repair of Thoracic Aorta Via a Percutaneous Popliteal Approach Following an Iatrogenic Injury.

Iatrogenic arterial injuries are rare but well-recognised complications of spinal surgery. This paper presents a case of an iatrogenic arterial injury during a total en bloc spondylectomy resulting in significant haemorrhage and the patient's haemodynamic instability. The devastating complication was successfully treated with an emergency thoracic endovascular aortic repair via a percutaneous popliteal approach, while the patient remained in prone position. The patient had an uneventful recovery with no subsequent arterial injury or pseudoaneurysm to the access vessel.

Vascular imaging immediately after tourniquet removal does not increase vasospasm risk.

BACKGROUND: Prehospital tourniquet use is now standard in trauma patients with diagnosed or suspected extremity vascular injuries. Tourniquet-related vasospasm is an understudied phenomenon that may confound management by causing erroneous arterial pressure indices (APIs) and abnormalities on computed tomography angiography (CTA) that do not reflect true arterial injuries. We hypothesized that shorter intervals between tourniquet removal and CTA imaging and longer total tourniquet times would be correlated with a higher likelihood of false positive CTA. MATERIALS AND METHODS: We performed a single-institution retrospective cohort study of patients presenting to a busy, urban Level 1 Trauma Center with prehospital tourniquets from 2019 to 2021. Patients who presented with a tourniquet disengaged upon arrival or who died prior to admission to the Trauma Unit were excluded. Tourniquet duration, time between tourniquet removal and CTA imaging (CTA interval), CTA findings, and management of extremity arterial injuries were extracted. The proportion of false positive injuries on CTA was assessed for correlation with increasing time interval from tourniquet removal to CTA imaging and correlation with increasing total tourniquet time using multivariable logistic regression. RESULTS: 251 patients were identified with prehospital tourniquets. 127 underwent CTA of the affected extremity, 96 patients had an abnormal CTA finding, and 57 (45% of total CTA patients) had false positive arterial injuries on imaging. Using multivariable logistic regression, neither the CTA interval nor the tourniquet duration was associated with false positive CTA injuries. Female sex was associated with false positive injuries on CTA (OR 2.91, 95% CI: 1.01 - 8.39). Vasospasm was cited as a possible explanation by radiologists in 40% of false positive CTA reports. CONCLUSIONS: Arterial vasospasm is a frequent finding on CTA after tourniquet use for extremity trauma, but concerns regarding tourniquet-related vasospasm should not alter trauma patient management. Neither the duration of tourniquet application nor the time interval since removal is associated with decreased CTA accuracy, and any delay in imaging does not appear to reduce the likelihood of vasospasm. These findings are important for supporting expedited care of trauma patients with severe extremity injuries.

A Review of Radiation-Induced Vascular Injury and Clinical Impact.

ABSTRACT: The number of cancer survivors continues to increase because of advances in therapeutic modalities. Along with surgery and chemotherapy, radiotherapy is a commonly used treatment modality in roughly half of all cancer patients. It is particularly helpful in the oncologic treatment of patients with breast, head and neck, and prostate malignancies. Unfortunately, among patients receiving radiation therapy, long-term sequalae are often unavoidable, and there is accumulating clinical evidence suggesting significant radiation-related damage to the vascular endothelium. Ionizing radiation has been known to cause obliterative fibrosis and increased wall thickness in irradiated blood vessels. Clinically, these vascular changes induced by ionizing radiation can pose unique surgical challenges when operating in radiated fields. Here, we review the relevant literature on radiation-induced vascular damage focusing on mechanisms and signaling pathways involved and highlight microsurgical anastomotic outcomes after radiotherapy. In addition, we briefly comment on potential therapeutic strategies, which may have the ability to mitigate radiation injury to the vascular endothelium.

Cross-Limb Vascular Shunting for Traumatic Popliteal Artery Injury.

BACKGROUND: Popliteal artery injury (PAI) is a challenging trauma that requires prompt and accurate treatment since the probability of lower-limb amputation increases with the ischemic time. Intravascular shunting and cross-limb vascular shunting (CLS) are used as temporary vascular shunting (TVS) methods to shorten the ischemic time for limb vascular injury. CLS involves sending blood from an artery in a healthy body part to a peripheral vessel in an injured part to immediately resume blood flow to the injured limb. For closed injuries including PAI, CLS may be performed without exploring and identifying the arterial stumps and it enables early reperfusion to the ischemic limb. We report the case series of traumatic PAI treated using CLS and verify the usefulness of CLS. METHODS: All patients with traumatic PAI treated with CLS at our institution between August 2013 and December 2021 were included. Demographic and clinical patient characteristics were extracted from the medical records. Comorbid injuries, severity of acute limb ischemia based on the Rutherford grading scale, time from injury to reperfusion by CLS, time from injury to completion of artery, and the use of fasciotomy were investigated. As outcomes, we investigated the presence or absence of lower extremity amputation during the course of treatment. RESULTS: We used CLS as treatment for 5 cases with traumatic PAI. Based on the Rutherford grading scale for acute limb ischemia, there were one limb with grade 2B and 4 with grade 3. Amputation of the lower extremities was avoided except for 1 extremity in which arterial reconstruction was not achieved due to unexplained cardiac arrest during surgery. CONCLUSIONS: CLS enables early reperfusion of the injured limb and is effective as a TVS method for traumatic PAI with severe ischemia or soft tissue damage.

Axillary Artery Injuries Associated With Proximal Humerus Fractures: A Literature Review and a Proposal of a Novel Multidisciplinary Surgical Approach.

INTRODUCTION: Proximal humerus fractures (PHF) are common injuries that can lead to axillary artery injury, which carries the risk of not being identified during initial assessment. The aim of this study was to describe the management of suspected axillary artery injury associated with PHF according to our experience and to describe a new multidisciplinary surgical approach. METHODS: This was a single-center retrospective study. A database was created for patients admitted for PHF to the emergency department of the Hospital of Cannes between October 2017 and October 2019. Patients admitted with PHF associated with suspected ipsilateral upper limb ischemia, and/or massive diaphysis displacement, and/or upper limb ipsilateral neurological deficits were included in this study. RESULTS: In total, 301 patients diagnosed with PHF were admitted within these periods. Among these patients, 12 presented with suspected axillary artery lesions, of whom, 6 were included in the present study and treated according to our new approach. A description of these 6 cases, along with an extensive literature review is presented. CONCLUSION: Based on our experience, the endovascular approach proposed for the management of axillary artery injury associated with proximal humerus fractures is effective, feasible and reproducible.

The Anatomical Course of the Superior Gluteal Vessel Bundle with Regard to Different Approaches in Total Hip Arthroplasty.

BACKGROUND: Iatrogenic vascular injury during total hip arthroplasty (THA) is rare, reported at rates of 0.05 to 0.3%, but a potentially limb-threatening and life-threatening complication. We aimed to describe safe and danger zones for the superior gluteal vessel bundle (SGV bundle) with reference to different THA approaches. METHODS: There were 27 formalin-fixed cadavers with 49 hemipelves dissected. The course and distribution of the SGV bundle were investigated with the help of anatomical landmarks like the greater trochanter, the iliac tubercle (IT), and the ischial tuberosity. RESULTS: We found and exposed the SGV bundle in all 49 specimens with no sex-specific differences. No SGV bundle was encountered up to 28 mm from the greater trochanter and up to 16 mm below the IT. The zone with the highest probability of finding the vessels was 25 to 65 mm below the IT in 39 (80%) cases - defining a danger zone (in relation to the skin incision) in the proximal fourth for the direct anterior approach, in the proximal half for the antero-lateral approach, in the proximal fifth for the direct lateral approach, and almost no danger zone for the posterior approach. CONCLUSIONS: Special care in proximal instrument placement should be taken during THA. When extending one of the surgical approaches, manipulations in the proximal, cranial surgical window should be performed with the utmost care to avoid SGV bundle injury.

The Order of Operative Repair Does Not Influence Outcomes in Patients with Concomitant Popliteal Artery and Orthopedic Injuries.

BACKGROUND: The most challenging lower extremity traumatic injuries involve concomitant vascular and orthopedic injuries with amputation rates approaching 50%. Controversy exists as to how to prioritize the vascular and orthopedic repairs. We reviewed patients with popliteal artery and lower extremity orthopedic injuries to analyze the sequence of the vascular and orthopedic repairs on outcomes. METHODS: All adult patients with a diagnosis of concomitant popliteal artery and lower extremity fracture or dislocation were identified through a review of an institutional trauma registry performed at a level 1 trauma center from 2014 to 2019. Patient demographics, timing of presentation, injury severity score (ISS), surgical interventions, and limb outcome data were collected and examined. The sequence of operative repairs and factors influencing the operative order were analyzed. RESULTS: Twenty-nine patients were treated for popliteal artery injuries. Twelve of these 29 patients had concomitant popliteal artery and orthopedic fractures requiring surgical repair. Injury mechanisms included both blunt (50%, 6/12) and penetrating trauma (50%, 6/12); the majority involved femur fractures (58%, 7/12). Vascular repair included arterial bypass (75%, 9/12) or interposition grafts (25%, 3/12). Orthopedic repair included external fixation (83%, 10/12) and open reduction internal fixation (17%, 2/12). Vascular repair was performed first in 7/12 limbs (58%). Patients having vascular repair first had a trend toward lower blood pressure on arrival (P = 0.068). There was no significant difference in emergency department to operating room (OR) time, OR time, ISS, mangled extremity severity score, estimated blood loss, or blood transfusion for the sequence of operative repair. Fasciotomy was nearly ubiquitous, present in 11/12 patients (92%). There were no graft complications related to orthopedic manipulation, and there were no reported limb-length to graft-length discrepancies. Early limb salvage trended lower in the cohort with revascularization first (71% vs. 100%, P = 0.19). Of the remaining limbs available for follow-up, limb salvage at 4.25 years is 100%. CONCLUSIONS: In this small study of patients with concomitant lower extremity popliteal artery and orthopedic injuries, the order of operative repair does not appear to influence the success of revascularization.

Iatrogenic Carotid Artery Pseudoaneurym: Successful Treatment With Percutaneous Thrombin Injection.

This report demonstrates the successful treatment of a carotid artery pseudoaneurysm using percutaneous thrombin injection. The patient, a 62-year-old woman with multiple comorbidities, experienced a pseudoaneurysm following an unintentional carotid artery puncture during a failed attempt to place a triple lumen catheter in the right jugular vein. Percutaneous thrombin injection was chosen as the treatment method, with Doppler ultrasound monitoring. Follow-up examinations showed no signs of recurrence, and the patient was discharged after nine days without complications.

Traumatic Iliac Arteriovenous Fistula Treated With the Amplatzer Vascular Plug II: A Case Report and Literature Review.

Traumatic iliac arteriovenous fistula is a rare complication of vascular injury. Open surgical repair has an incidence of postoperative complications. In recent years, endovascular treatment has shown better efficacy. We report a 62-year-old female AVF patient with a stab injury history of more than 16 years. Computed tomography angiography (CTA) revealed a large arteriovenous fistula between the right internal iliac artery and the common iliac vein. After considering the patient's relevant conditions, an endovascular approach was satisfactorily performed with the implantation of an Amplatzer Vascular Plug II to interrupt the abnormal vascular communication and maintain arterial and venous patency. The final control images showed closure of the arteriovenous communication.