Damage-control vascular surgery in Canada: supporting surgeons and teams.

SummaryIn Canada, trauma patients often present initially to non-trauma hospitals without vascular surgeons on site. Local surgeons need skills and support for damage-control vascular surgery. Canadian training programs in general surgery should equip trainees with skills in this area, including resuscitation, identification of vascular injury, hemorrhage control, and temporizing measures (e.g., shunts, ligation). Caring for trauma patients is a multidisciplinary endeavour; understanding local/regional skill sets and from whom to seek help is vital. Opportunities for skills maintenance should also be encouraged for surgeons practising at sites where acutely injured patients present.

Our experience with blast and gunshot induced traumatic vascular injuries at Somalia's major vascular referral center.

Blast and gunshot-induced penetrating traumatic vascular injuries represent a significant portion of patients with vascular trauma in countries where there are higher rates of war-related violence. These injuries are especially challenging in resource-limited countries due to early diagnosis and transfer delays. This report aimed to present our experience regarding the surgical management and outcome of such injuries at a major referral vascular surgery centre in the country. A retrospective descriptive review of 326 patients with blast and gunshot-induced penetrating traumatic vascular injuries managed during a five-year period between April 2018 and April 2023. The demographics, mechanism of injury, type of vascular injury, Anatomical location, time to the operation, length of hospital stay, amount of blood products given, concomitant neuroskeletal injuries, development of Vascular injury associated acute kidney injury, surgical procedures performed and patient outcome were reviewed. In this study, 326 patients with 445 vascular injuries fulfilled the inclusion criteria. Most of the patients were male 92.3%, and the mean age was 28.3 ± 9.9 years. The gunshot mechanism of vascular injury was implicated in 76.1% of the injuries, and explosive-induced injury was 78 (23.9%). 193 (59.2%) of the patients had isolated arterial injuries, 117 (35.9%) patients had combined arterial and venous injuries while 18 (4.9%) patients had isolated venous injuries. The most commonly injured arteries were the femoral artery, followed by Brachial and popliteal artery injuries (26.1%, 23.5% and 19.4%, respectively). The median time to revascularization was 8.8 ± 8.7 h. 46.8% of the patients had Concomitant fractures, while 26.5% had Concomitant nerve injuries. Only three patients had temporary non-heparin-bound shunts during their arrival. The most common surgical intervention in arterial injuries was reversed saphenous vein graft 46.1%. The mortality was 5.8% and 7.7% of the patients needed secondary amputation. The majority of wartime arterial injuries are a result of Blast and gunshot vascular injuries. Frequent need for autologous vein grafts should be considered to manage such injuries. Results are encouraging despite delays in intervention; therefore, all viable limbs should be revascularized, keeping in mind the long-term functionality of the limb.

Systematic review and meta-analysis of endovascular therapy versus open surgical repair for the traumatic lower extremity arterial injury.

OBJECTIVE: For traumatic lower extremity artery injury, it is unclear whether it is better to perform endovascular therapy (ET) or open surgical repair (OSR). This study aimed to compare the clinical outcomes of ET versus OSR for traumatic lower extremity artery injury. METHODS: The Medline, Embase, and Cochrane Databases were searched for studies. Cohort studies and case series reporting outcomes of ET or OSR were eligible for inclusion. Robins-I tool and an 18-item tool were used to assess the risk of bias. The primary outcome was amputation. The secondary outcomes included fasciotomy or compartment syndrome, mortality, length of stay and lower extremity nerve injury. We used the random effects model to calculate pooled estimates. RESULTS: A total of 32 studies with low or moderate risk of bias were included in the meta-analysis. The results showed that patients who underwent ET had a significantly decreased risk of major amputation (OR = 0.42, 95% CI 0.21-0.85; I2=34%) and fasciotomy or compartment syndrome (OR = 0.31, 95% CI 0.20-0.50, I2 = 14%) than patients who underwent OSR. No significant difference was observed between the two groups regarding all-cause mortality (OR = 1.11, 95% CI 0.75-1.64, I2 = 31%). Patients with ET repair had a shorter length of stay than patients with OSR repair (MD=-5.06, 95% CI -6.76 to -3.36, I2 = 65%). Intraoperative nerve injury was just reported in OSR patients with a pooled incidence of 15% (95% CI 6%-27%). CONCLUSION: Endovascular therapy may represent a better choice for patients with traumatic lower extremity arterial injury, because it can provide lower risks of amputation, fasciotomy or compartment syndrome, and nerve injury, as well as shorter length of stay.

Pediatric Peripheral Vascular Trauma: Incidence and Outcomes.

Peripheral vascular trauma (PVT) is rare in children, with an incidence estimated below 1%. We studied pediatric PVT and risk factors for major amputation by accessing the 2019 National Trauma Data Bank (NTDB). Demographics, injury type and location, trauma center capability, injury severity score (ISS), length of stay (LOS), and major amputation rates were evaluated. Statistical analysis included chi-square testing for categorical variables and t-tests for continuous variables. Of 130,554 pediatric trauma patients, 1196 (.9%) had 1460 upper extremity (UE) and lower extremity (LE) PVT. Patients were predominantly male (n = 933, 78%) with a mean age of 14 years. Most patients suffered penetrating injury (n = 744, 62.2%). The most common vessels injuries were radial (n = 198, 13.6%) and femoral (n = 196, 13.4%). Major amputation occurred in 2.6% of patients (n = 31). Patients who suffered blunt injury (OR, 3.3; 95% CI, 1.5-7.5; P = .004) and lower limb PVT (OR, 11.1; 95% CI, 3.3-37.9, P = .0001) had higher odds of amputation.

Risk Factors for Venous Thromboembolism and Eventual Amputation in Traumatic Femoral and Iliac Vein Injuries: A Trauma Quality Improvement Program Analysis.

BACKGROUND: Iliac and femoral venous injuries represent a challenging dilemma in trauma surgery with mixed results. Venous restoration of outflow (via repair or bypass) has been previously identified as having higher rates of VTE (venous thromboembolism) compared to ligation. We hypothesized that rates of VTE and eventual amputation were similar whether restoration of venous outflow vs ligation was performed at initial operation. METHODS: Patients in the 2019-2021 National Trauma Data Bank with iliac and femoral vein injuries were abstracted and analyzed. The primary outcomes of interest were in-hospital lower extremity amputation and VTE. RESULTS: A total of 2642 patients with operatively managed iliac and femoral vein injuries were identified VTE was found in 10.8% of patients. Multivariable logistic regression was performed and identified bowel injury, higher ISS, older age, open repair, and longer time to VTE prophylaxis initiation as independent predictors of VTE. Amputation was required in 4.2% of patients. Multivariable logistic regression identified arterial or nerve injury, femur or tibia fracture, venous ligation, percutaneous intervention, fasciotomy, bowel injury, and higher ISS as independent factors of amputation. CONCLUSION: Venous restoration was not an independent predictor of VTE. Venous ligation on index operation was the only modifiable independent predictor of amputation identified on regression analysis.

Management of vascular injuries on ICU patients: KZN experience.

BACKGROUND: Vascular injury management remains an extremely challenging task. The fundamental principles of management are bleeding arrest and flow restoration, to avoid death and amputation. With advances in medicine, there has been a shift from ligation to primary repair which has resulted in a fall in amputation rate from 50 % in World War II to less than 2 % in civilian injuries. METHOD: A retrospective cross-sectional study was conducted on ICU requiring polytrauma patients with vascular trauma admitted between January 2013 and December 2021. Additional data were collected prospectively from January 2022 to December 2022. All data was from an ethics approved Trauma Registry. The injury was either confirmed by imaging or via exploration. The pre-designed data proforma acquired the following variables: age, mechanism of injury, injured vessel, associated injury, management of the vessel, and management of the associated injury. The data were analysed using Stata version 17 (StataCorp, College Station TX). Frequencies and percentages were calculated to summarise numerical data An ethical clearance was granted by the University of KwaZulu-Natal BREC (BREC 0004353/2022) and the KZN Department of Health. All data were de-identified in the data collection sheet. RESULTS: There were 154 arterial injuries and 39 venous injuries. The majority, 77 (50 %) of arterial injuries were managed via open strategies, and 36 (23 %) were managed via endovascular intervention. The majority, 20 (51 %) of venous injuries underwent open ligation, and 12 (31 %) were managed non-surgically. The highest number of endovascular interventions was observed in aortic injuries. For a total of 25 aortic injuries, 22 (83 %) were managed endovascular (TEVAR) and 2 (8 %) were managed non-operatively. CONCLUSION: The choice between the endovascular and open approach depends on the injured blood vessel. The majority of venous injuries were treated with open ligation in this cohort.

A 12-year experience in the management of blunt thoracic aortic injury in Otautahi Christchurch.

BACKGROUND: Blunt thoracic aortic injury (BTAI) is associated with a high mortality and is the second most common cause of death from trauma. The approach to major trauma, imaging technology and advancement in endovascular therapy have revolutionised the management of BTAI. Endovascular therapy has now become the gold standard technique replacing surgery with its high mortality and morbidity in unstable patients. We aim to assess the outcomes following management of BTAI. METHOD: This is a retrospective study of all patients with BTAI between 1 January 2010 and 1 January 2022. Data were obtained from electronic health records. The grading of BTAI severity was done based on the Society of Vascular Surgery (SVS) Criteria. RESULTS: Fifty patients were included in the study analysis. The most common cause of BTAI was due to high-speed motor vehicle accidents (MVA) (36 patients, 72%). Grade 1 and grade 3 BTAI injuries were mostly encountered in 40% and 30% of the study cohort, respectively. Twenty-three patients (46%) underwent thoracic endovascular aortic repair (TEVAR). There was no secondary aortic re-intervention, conversion to open surgery or aortic-related deaths at 30 days or at most recent follow-up. CONCLUSION: Management of BTAI in our centre compares well with currently published studies. Long-term studies are warranted to guide clinicians in areas of controversy in BTAI management.

Evaluating the Need for Simultaneous Carpal Tunnel Release With Forearm Fasciotomy.

PURPOSE: The need to include simultaneous carpal tunnel release (sCTR) with forearm fasciotomy for acute compartment syndrome (ACS) or after vascular repair is unclear. We hypothesized that sCTR is more common when: 1) fasciotomies are performed by orthopedic or plastic surgeons, rather than general or vascular surgeons; 2) ACS occurred because of crush, blunt trauma, or fractures rather than vascular/reperfusion injuries; 3) elevated compartment pressures were documented. We also sought to determine the incidence of delayed CTR when not performed simultaneously. METHODS: Retrospective chart review identified patients who underwent forearm fasciotomy for ACS or vascular injury over a period of 10 years. Patient demographics, mechanism of ACS or indication for fasciotomy, surgeon subspecialty, compartment pressure measurements, inclusion of sCTR, complications, reoperations, and timing and method of definitive closure were analyzed. Logistic regression modeling was used to analyze predictors associated with delayed CTR. RESULTS: Fasciotomies were performed in 166 patients by orthopedic (63%), plastic (28%), and general/vascular (9%) surgeons. Orthopedic and plastic surgeons more frequently performed sCTR (67% and 63%, respectively). A total of 107 (65%) patients had sCTR. Fasciotomies for vascular/reperfusion injury were more likely to include sCTR (44%) compared with other mechanisms. If not performed simultaneously, 11 (19%) required delayed CTR at a median of 42 days. ACS secondary to fracture had the highest rate of delayed CTR (35%), and the necessity of late CTR for fractures was not supported by the logistic regression model. Residual hand paresthesias were less frequent in the sCTR group (6.5% vs 20%). Overall complication rates were similar in both groups (63% sCTR vs 70% without sCTR). CONCLUSION: When sCTR is excluded during forearm fasciotomy, 19% of patients required delayed CTR. This rate was higher (35%) when ACS was associated with fractures. Simultaneous CTR with forearm fasciotomy may decrease the incidence of residual hand paresthesias and the need for a delayed CTR. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognosis IV.

Nonoperative Management for Low-Grade Blunt Thoracic Aortic Injury.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) is the standard of care for the treatment of blunt thoracic aortic injury (BTAI) requiring intervention. Data suggest that low-grade BTAI (grade I [intimal tears] or grade II [intramural hematoma]) will resolve spontaneously if treated with nonoperative management (NOM) alone. There has been no comparison specifically between the use of NOM vs TEVAR for low-grade BTAI. We hypothesize that these low-grade injuries can be safely managed with NOM alone. STUDY DESIGN: Retrospective analysis of all patients with a low-grade BTAI in the Aortic Trauma Foundation Registry from 2016 to 2021 was performed. The study population was 1 primary outcome was mortality. Secondary outcomes included complications, ICU length of stay, and ventilator days. RESULTS: A total of 880 patients with BTAI were enrolled. Of the 269 patients with low-grade BTAI, 218 (81%) were treated with NOM alone (81% grade I, 19% grade II), whereas 51 (19%) underwent a TEVAR (20% grade I, 80% grade II). There was no difference in demographic or mechanism of injury in patients with low-grade BTAI who underwent NOM vs TEVAR. There was a difference in mortality between NOM alone and TEVAR (8% vs 18%, p = 0.009). Aortic-related mortality was 0.5% in the NOM group and 4% in the TEVAR group (p = 0.06). Hospital and ICU length of stay and ventilator days were not different between the 2 groups. CONCLUSIONS: NOM alone is safe and appropriate management for low-grade BTAI, with lower mortality and decreased rates of complication when compared with routine initial TEVAR.

Long-term outcomes of autologous vein bypass for repair of upper and lower extremity major arterial trauma.

OBJECTIVE: Autologous vein is the preferred bypass conduit for extremity arterial injuries owing to superior patency and low infection risk; however, long-term data on outcomes in civilians are limited. Our goal was to assess short- and long-term outcomes of autologous vein bypass for upper and lower extremity arterial trauma. METHODS: A retrospective review was performed of patients with major extremity arterial injuries (2001-2019) at a level I trauma center. Demographics, injury and intervention details, and outcomes were recorded. Primary outcomes were primary patency at 1 year and 3 years. Secondary outcomes were limb function at 6 months, major amputation, and mortality. Multivariable analysis determined risk factors for functional impairment. RESULTS: There were 107 extremity arterial injuries (31.8% upper and 68.2% lower) treated with autologous vein bypass. Mechanism was penetrating in 77% of cases, of which 79.3% were due to firearms. The most frequently injured vessels were the common and superficial femoral (38%), popliteal (30%), and brachial arteries (29%). For upper extremity trauma, concomitant nerve and orthopedic injuries were found in 15 (44.1%) and 11 (32.4%) cases, respectively. For lower extremities, concomitant nerve injuries were found in 10 (13.7%) cases, and orthopedic injuries in 31 (42.5%). Great saphenous vein was the conduit in 96% of cases. Immediate intraoperative bypass revision occurred in 9.3% of patients, most commonly for graft thrombosis. The in-hospital return to operating room rate was 15.9%, with graft thrombosis (47.1%) and wound infections (23.5%) being the most common reasons. The median follow-up was 3.6 years. Kaplan-Meier analysis showed 92% primary patency at 1 year and 90% at 3 years. At 6 months, 36.1% of patients had functional impairment. Of patients with functional impairment at 6 months, 62.9% had concomitant nerve and 60% concomitant orthopedic injuries. Of those with nerve injury, 91.7% had functional impairment, compared with 17.8% without nerve injury (P < .001). Of patients with orthopedic injuries, 51.2% had functional impairment, vs 25% of those without orthopedic injuries (P = .01). On multivariable analysis, concomitant nerve injury (odds ratio, 127.4; 95% confidence interval, 17-957; P <. 001) and immediate intraoperative revision (odds ratio, 11.03; 95% confidence interval, 1.27-95.55; P = .029) were associated with functional impairment. CONCLUSIONS: Autologous vein bypass for major extremity arterial trauma is durable; however, many patients have long-term limb dysfunction associated with concomitant nerve injury and immediate intraoperative bypass revision. These factors may allow clinicians to identify patients at higher risk for functional impairment, to outline patient expectations and direct rehabilitation efforts toward improving functional outcomes.

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.

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.

Para-aortic lymphadenectomy in endometrial cancer patients with left-sided inferior vena cava: A case report and literature review.

OBJECTIVE: The incidence of left-sided inferior vena cava (IVC) is extremely low. However, without a preoperative diagnosis of left-sided IVC, the risk of intraoperative vascular injury during para-aortic lymph node (PAN) lymphadenectomy is high. CASE REPORT: Herein, we present two cases in which left-sided IVCs were diagnosed using preoperative imaging. PAN lymphadenectomies were safely performed in these patients with endometrial cancer. In the first case, the left-sided IVC crossed the abdominal aorta after the left renal and gonadal veins had drained into it and joined the right renal vein. In the second case, the left-sided IVC crossed the abdominal aorta after the left renal and gonadal veins flowed into it and the ascending lumbar vein flowed into the right side. CONCLUSION: These cases demonstrate that even in the presence of vascular malformations, PAN lymphadenectomy can be performed safely by employing preoperative anatomical imaging analysis and judicious intraoperative surgical maneuvers to avoid vascular injury.

Wartime Endovascular Therapy: A Historical View.

Endovascular techniques for managing vascular trauma have become increasingly more common. However, these techniques have had limited application in recent conflicts. Using lessons from 20th century conflicts, the present study aims to highlight how advances made in the past may provide a roadmap to improving surgical capabilities in the future.

Tranexamic acid is not associated with a higher rate of thrombotic-related reintervention after major vascular injury repair.

BACKGROUND: Tranexamic acid (TXA) is associated with lower mortality and transfusion requirements in trauma patients, but its role in thrombotic complications associated with vascular repairs remains unclear. We investigated whether TXA increases the risk of thrombosis-related technical failure (TRTF) in major vascular injuries (MVI). METHODS: The PROspective Observational Vascular Injury Treatment (PROOVIT) registry was queried from 2013 to 2022 for MVI repaired with an open or endovascular intervention. The relationship between TXA administration and TRTF was examined. RESULTS: The TXA group (n = 297) had higher rates of hypotension at admission (33.6% vs. 11.5%, p < 0.001), need for continuous vasopressors (41.4% vs. 18.4%, p < 0.001), and packed red blood cell transfusion (3.2 vs. 2.0 units, p < 0.001) during the first 24 hours compared with the non-TXA group (n = 1941), although demographics, injury pattern, and interventions were similar. Cryoprecipitate (9.1% vs. 2%, p < 0.001), and anticoagulant administration during the intervention (32.7% vs. 43.8%, p < 0.001) were higher in the TXA group; there was no difference in the rate of factor VII use between groups (1% vs. 0.7%, p = 0.485). Thrombosis-related technical failure was not different between the groups (6.3% vs. 3.8 p = 0.141) while the rate of immediate need for reoperation (10.1% vs. 5.7%, p = 0.006) and overall reoperation (11.4% vs. 7%, p = 0.009) was significantly higher in the TXA group on univariate analysis. There was no significant association between TXA and a higher rate of immediate need for reintervention (odds ratio [OR], 1.19; 95% confidence interval [CI], 0.75-1.88; p = 0.465), overall reoperation rate (OR, 1.33; 95% CI, 0.82-2.17; p = 0.249) and thrombotic events in a repaired vessel (OR, 1.07; 95% CI, 0.60-1.92; p = 0.806) after adjusting for type of injury, vasopressor infusions, blood product and anticoagulant administration, and hemodynamics. CONCLUSION: Tranexamic acid is not associated with a higher risk of thrombosis-related technical failure in traumatic injuries requiring major vascular repairs. Further prospective studies to examine dose-dependent or time-dependent associations between TXA and thrombotic events in MVIs are needed. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

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.

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.

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.