Iatrogenic arterial injuries of spine and orthopedic operations.

OBJECTIVE: To describe the results of contemporary management of iatrogenic arterial injuries following spine and orthopedic operations. METHODS: Patients with major arterial injuries following spine and orthopedic operations in four teaching hospitals (Henry Ford Hospital, Detroit, Mich; Henry Ford Macomb Hospital, Clinton Township, Mich; St John Macomb Hospital, Warren, Mich; and St John Hospital, Detroit, Mich) over the last 10 years were studied. Data were collected on a continuous basis from vascular registries and analyzed retrospectively. RESULTS: Seventeen patients (8 spine, 9 orthopedic operations) had iatrogenic arterial injuries manifest as thrombosis or laceration with bleeding, pseudoaneurysm, or arteriovenous fistula. The majority of arterial lacerations with bleeding and pseudoaneurysms were treated with open surgical repair while the majority of thromboses and arteriovenous fistulae were treated with endovascular techniques. Fasciotomy was necessary in three of seven patients with arterial complications of knee and hip operations. There was no mortality or limb loss. Significant morbidity in the form of foot drop (1), iliac vein thrombosis (2), delayed ambulation due to hematoma and swelling of the lower extremity (2), and ischemic myonecrosis of calf muscles (1) occurred. Two patients launched legal action. CONCLUSION: Arterial injuries following orthopedic and spine operations can be successfully managed by both open and endovascular techniques. Significant morbidity and increased length of stay is common. Patient dissatisfaction with the complication and need for ensuing treatment can have significant medicolegal consequences.

The evaluation of morbidity and mortality in abdominal aortic aneurysm repair patients as related to body mass index.

BACKGROUND: This study evaluates the relationship between body mass index (BMI) and other comorbidities on the overall morbidity and mortality of abdominal aortic aneurysm (AAA) repair. METHODS: A database of all nonemergent open and endovascular AAA repairs performed at our center from 2004 to 2008 was created. The outcomes at the predefined time intervals were then evaluated for each group of patients. RESULTS: One hundred forty-three patients qualified for this study with a 3:2 stent graft-to-open ratio. A trend relating patient BMI with early mortality was noted. Age>80 years was a strong predictor of mortality in all time intervals. CONCLUSIONS: The outcomes for this population show a significant trend toward early mortality in open AAA repair patients with an elevated preoperative BMI. Appropriate patient selection and preoperative optimization are recommended for all AAA repair candidates; however, some innate characteristics such as patient age, may play the largest role in determining outcomes.

Duplex scanning-guided thrombin injection for the treatment of iatrogenic pseudoaneurysms.

PURPOSE: This study presents our current results with duplex scanning-guided thrombin injection (DGTI) for the treatment of lower-extremity iatrogenic pseudoaneurysms (PAs). These results were compared with the results from our patient population that was treated with duplex scanning-guided compression (DGC). METHODS: This was a prospective evaluation of an institutional review board-approved protocol for ultrasound scanning-guided thrombin injection for the treatment of iatrogenic lower-extremity PAs. The maneuver was performed with continuous real-time color ultrasound scanning imaging to guide a needle into a PA sac. Then 0.5 to 1.0 mL of a thrombin solution (1000 U/mL) was injected, and thrombosis of the sac was monitored. All patients underwent an arterial evaluation of the involved extremity before and after thrombin injection. In addition, the size of the PA and its parent artery were documented by means of pre-injection imaging. After thrombosis of the PA, the patient was kept on bed rest for 4 hours, and activity was limited that day (bathroom privileges for inpatients). Follow-up imaging was performed after 24 hours, and attempts were made to obtain imaging 1 week and 1 month after injection. RESULTS: In the 31 months of the study, 131 iatrogenic PAs of the lower extremity were initially treated with DGTI, and thrombosis was achieved in 126 of these cases (96%). Thrombosis of the PA sac was accomplished within seconds of thrombin injection. Five cases failed, three of which resulted from complications of the procedures, with two intra-arterial thrombin injections and one PA rupture after thrombosis. CONCLUSION: Our experience indicates that DGTI is more effective than DGC (96% vs 75%) in the treatment of iatrogenic lower-extremity PAs. The DGTI procedure is completed in minutes, compared with a mean compression time of 44 minutes with DGC, which leads to increased patient and operator acceptance. Intra-arterial thrombin injection was seen in 4% of PAs that were 2.6 cm or smaller and resulted in limb-threatening ischemia requiring surgical intervention. Finally, the use of a biopsy guide attached to the ultrasound scanning transducer head simplifies the visualization of the needle, reducing the number of needle punctures and needle manipulation.