Evidence Of Vascular Injury Research Articles

Temporal Bone Gunshot Wounds: A Multi-institutional Retrospective Study.

To investigate management practices and outcomes in a retrospective cohort of patients who have sustained temporal bone gunshot wounds (TBGSW). Retrospective chart review. Five participating hospitals. Twenty-two patients met inclusion criteria: experienced a TBGSW, survived ≥30 days following the injury, and were evaluated and managed by a neurotologist between 2019 and 2023. No specific interventions were performed for the purposes of this study. Characteristics, evaluation, management, and outcomes of TBGSW survivors. Patients were found to have a mean age of 33 ± 18 years and were predominantly male (18/22, 81.8%). Majority of patients (17/22, 77.3%) had mastoid injury. Most patients (14/22, 63.6%) had some evidence for vascular injury, most frequently the internal carotid artery (9/22, 40.9%). Almost three-quarters (17/22, 77.3%) of patients had clinical exam findings of facial nerve injury, which was the most common indication for surgery. Otologic surgery was performed in 72.7% (16/22), with delayed adverse events most commonly including cholesteatoma and external auditory canal stenosis. Though evidence for hearing impairment was clinically present in at least 15 of 22 patients (68.2%), hearing rehabilitation was pursued in only two patients. With increasing numbers of TBGSW survivors, there is a growing need for practicing neurotologists to be familiar with the wide spectrum of injury patterns and possible complications to inform clinical management in these patients. Early neurotologic assessment and follow-up beyond the acute period is crucial to minimize morbidity in this high-risk cohort.

Vascular injury arising from lateral skull base fractures

PurposeAlthough uncommon, vascular injury can be seen in patients with lateral skull base fractures (LSBF). However, little is known about this potentially life-threatening comorbidity. The objective of this study is to better characterize the vascular injuries associated with temporal and lateral sphenoid bone fractures. Basic proceduresRetrospective review of all patients with computed tomography angiography (CTA) performed specifically to evaluate for vascular injury following LSBF. In addition to patient demographics (age, gender, race), the mechanism of injury, the location of fracture(s), and the nature of vascular injury diagnosed by CTA was recorded. Two-way ANOVA was performed to determine if any variables were predictive of vascular injury. Main findingsFrom 2011 to 2021, 143 patients with 333 subsite fractures met inclusion criteria. Of all patients, 46 (32.2 %) had CTA evidence of at least one vascular injury, the most common type being venous thrombosis/filling defect (41.7 %). Evidence of vascular injury was unclear in 14 patients (9.8 %). Fractures most associated with vascular injury ranged from 0.7 % (otic capsule fractures) to 26.7 % (mastoid, lateral sphenoid fractures). Risk of vascular injury was no different between patients with single vs multiple fractures. There were no fracture locations that could reliably predict specific vascular injury. ConclusionsOver 40 % of all CTAs ordered following LSBF identified were suspicious for associated vascular injury. Yet fracture location and number cannot reliably predict vascular injury. Until such determinants can be better identified, clinicians should have a low threshold to obtain CTA to rule out associated vascular injury.

Optimizing Limb Salvage in Shotgun Injuries to the Extremities in Civilian Trauma

Vascular trauma in civilian settings has often resulted in high rates of amputation or mortality. Although treatment was individualized, patients were managed according to the following protocol: (1) Clinical evaluation and identification of those patients that require immediate exploration. (2) Determination of ankle-ankle indices, with a threshold of 0.9 mandating further evaluation. (3) Liberal use of computed tomography angiography (CTA) evaluation of injuries. (4) Selected use of digital subtraction angiography with an attempt to treat via endovascular means if there is thought to be a reasonable likelihood of success. (5) Liberal use of fasciotomy. (6) Reconstruction of arterial injury with contralateral reversed saphenous when available. (7) Postoperative follow-up with noninvasive arterial studies. Hypothesis: Protocol-driven early assessment and intervention can lead to excellent limb salvage in patients with civilian gunshot wound to the extremities. We retrospectively reviewed our gunshot database from 2012 to 2017 for patients with noniatrogenic penetrating vascular extremity injuries. Data analyzed were demographics, mode of injury, vessels injured, physical examination, arteriography findings, ischemic time, type of arterial and venous repair, morbidity, mortality, graft patency and functional outcome. Postoperative follow-up was done with noninvasive arterial studies. Sixteen patients sustained extremity injuries inflicted by shotguns. Fifteen (94%) underwent preoperative arteriography or CTA, revealing occult arterial injury in nine patients. One patient had soft tissue only and the other five who underwent CTA had no evidence of vascular injury. Forty-five percent of patients sustained concomitant venous injury; 64% of all venous injuries and 90% of femoropopliteal venous injuries were repaired. Eighty-one percent underwent fasciotomy at time of surgery. Fasciotomy occurred in 100% of patients with combined arterial and venous injuries (100%) versus 25% with isolated arterial injury. Arterial continuity was restored by interposition grafting with reversed saphenous vein (100%). There were no deaths or amputations at in-office follow-up, which ranged from 6 months to 7 years. Two patients had saphenous nerve injures, one of which fully recovered and the other patient ambulated with a cane due to nerve injury. A protocol of preoperative imaging with either arteriography or CTA for extremity shotgun injuries, use of fasciotomy, frequent use of autologous interposition grafts, repair of major venous injuries, and routine use of completion arteriography can result in limb salvage rates of 100% after shotgun vascular trauma to the extremities.

Early impact of moderate preterm birth on the structure, function and gene expression of conduit arteries

What is the central question of this study? What is the immediate impact of moderate preterm birth on the structure and function of major conduit arteries using a pre-clinical sheep model? What is the main finding and its importance? Postnatal changes in conduit arteries, including a significant decrease in collagen within the thoracic aortic wall (predominately males), narrowed carotid arteries, reduced aortic systolic blood flow, and upregulation of the mRNA expression of cell adhesion and inflammatory markers at 2days of age in preterm lambs compared to controls, may increase the risk of cardiovascular impairment in later life. The aim of this work was to compare the structure and function of the conduit arteries of moderately preterm and term-born lambs and to determine whether vascular injury-associated genes were upregulated. Time-mated ewes were induced to deliver either preterm (132±1days of gestation; n=11 females and n=10 males) or at term (147±1days of gestation; n=10 females and n=5 males). Two days after birth, ultrasound imaging of the proximal ascending aorta, main, right and left pulmonary arteries, and right and left common carotid arteries was conducted in anaesthetized lambs. Lambs were then killed and segments of the thoracic aorta and left common carotid artery were either snap frozen for real-time PCR analyses or immersion-fixed for histological quantification of collagen, smooth muscle and elastin within the medial layer. Overall there were few differences in vascular structure between moderately preterm and term lambs. However, there was a significant decrease in the proportion of collagen within the thoracic aortic wall (predominantly in males), narrowing of the common carotid arteries and a reduction in peak aortic systolic blood flow in preterm lambs. In addition, there was increased mRNA expression of the cell adhesion marker P-selectin in the thoracic aortic wall and the pro-inflammatory marker IL-1β in the left common carotid artery in preterm lambs, suggestive of postnatal vascular injury. Early postnatal differences in the function and structure of conduit arteries and evidence of vascular injury in moderately preterm offspring may place them at greater risk of cardiovascular impairment later in life.

The value of ultrasonic diagnosis in the management of vascular complications of supracondylar fractures of the humerus in children

Of 48 consecutive children with Gartland III supracondylar fractures, 11 (23%) had evidence of vascular injury, with an absent radial pulse. The hand was pink and warm in eight and white and cold in the other three patients. They underwent colour-coded duplex scanning (CCDS) and ultrasound velocimetry (UV) to investigate the patency of the brachial artery and arterial blood flow. In seven patients with a pink pulseless hand, CCDS showed a displaced, kinked and spastic brachial artery and a thrombosis was present in the other. In all cases UV showed reduced blood flow in the hand. In three patients with a white pulseless hand, scanning demonstrated a laceration in the brachial artery and/or thrombosis. In all cases, the fracture was reduced under general anaesthesia and fixed with Kirschner wires. Of the seven patients with a pink pulseless hand without thrombosis, the radial pulse returned after reduction in four cases. The remaining three underwent exploration, along with the patients with laceration in the brachial artery and/or thrombosis. We believe that the traditional strategy of watchful waiting in children in whom the radial pulse remains absent in spite of good peripheral perfusion should be revisited. Vascular investigation using these non-invasive techniques that are quick and reliable is recommended in the management of these patients.

Cavernous Carotid Pseudoaneurysm Following Transsphenoidal Surgery

Pseudoaneurysm of the internal carotid artery (ICA) as a result of injury during transsphenoidal surgery is a rare but serious complication. We present a review of this subject, identifying 22 such cases in the literature, and contribute an unusual case of our own. Among our cohort, 23% of patients had no evidence of vascular injury or hemorrhage during the initial transsphenoidal operation, and presented at an average of 83 days after surgery. The average time to diagnosis for patients with intraoperative bleeding was 64 days after surgery. Epistaxis was the most common initial presenting symptom, seen in 41% of patients, and traditional angiography was employed in every case to make the diagnosis of pseudoaneurysm. Though complete occlusion of the ICA was ultimately required in 41% of patients, the remainder were treated with a variety of modalities. While intraoperative hemorrhage is certainly the most predictive indicator of iatrogenic vascular damage, in its absence, other signs such as postoperative bruits may be predictive of pseudoaneurysm formation as well. The continued accumulation of these unique cases will hopefully provide definitive recommendations on the early recognition and treatment of this serious condition, especially regarding the emerging role of endovascular therapy in its management.

Proximal Clavicle Physeal Fracture With Posterior Displacement: Diagnosis, Treatment, and Prevention

Posterior sternoclavicular fracture displacement can present as a posterior sternoclavicular joint dislocation and is rare in the pediatric population. This article provides an algorithm for evaluation and management.A 14-year-old boy with a previously undiagnosed posterior sternoclavicular displacement presented with persistent 7/10 shoulder pain extending into his neck after undergoing nonoperative treatment for an unconfirmed diagnosis at another emergency department. Plain radiographs revealed a displacement of the right medial clavicle, and the position of the clavicular head indicated advanced imaging. Computed tomography showed the posterior portion of the clavicular head butting against the left braciocephalic vein at its confluence with the superior vena cava. The patient underwent open reduction and internal fixation. After exposing the sternoclavicular joint, a Salter-Harris I fracture with no evidence of vascular injury was confirmed. The fracture was reduced and stabilized using figure-eight #5 Ethibond sutures (Ethicon, Somerville, New Jersey), and the patient was placed in an immobilizer for 1 week. At 1 year postoperatively, the patient regained full range of motion and was completely healed.Posterior clavicle displacements are potentially devastating injuries that are difficult to diagnose. Coordinating operative treatment with orthopedic and general surgery is indicated to manage the fracture or displacement and potential vascular injury. Due to difficulties in maintaining a closed reduction, open reduction and internal fixation is the preferred mode of treatment for the reduction of all posterior clavicular fracture displacements.

Targeted Endovascular Temporary Vessel Occlusion with a Reverse Thermosensitive Polymer for Near-Bloodless Partial Nephrectomy: Comparison to Standard Surgical Clamping Techniques

To determine whether reversible blood flow interruption to a randomly chosen target region of the kidney may be achieved with the injection of a reverse thermoplastic polymer through an angiographic catheter, thereby facilitating partial nephrectomy without compromising blood flow to the remaining kidney or adding risks beyond those encountered by the use of hilar clamping. Fifteen pigs underwent partial nephrectomy after blood flow interruption by vascular cross-clamping or injection of polymer (Lumagel™) into a segmental artery. Five animals were euthanized after surgery (three open and two laparoscopic resection, cross-clamping n = 2), and 10 (open resection, cross-clamping n = 4) were euthanized after 6 weeks' survival. Blood specimens were obtained periodically, and angiogram and necropsy were performed at 6 weeks. Selective renal ischemia was achieved in all cases. Surgical resection time averaged 9 and 24.5 min in the open and laparoscopic groups, respectively. Estimated blood loss was negligible with the exception of one case where an accessory renal artery was originally overlooked. Reversal of the polymer to a liquid state was consistent angiographically and visually in all cases. Time to complete flow return averaged 7.4 and 2 min for polymer and clamping, respectively. Angiography at 6 weeks revealed no evidence of vascular injury. Laboratory data and necropsies revealed no differences between animals undergoing vascular clamping or polymer injection. Lumagel was as effective as vascular clamping in producing a near bloodless operative field for partial nephrectomy while maintaining flow to the uninvolved portion of the affected kidney.

Autoimmune-Mediated Vascular Injury Occurs Prior to Sustained Hyperglycemia in a Murine Model of Type I Diabetes Mellitus

Accelerated cardiovascular disease in patients with type I diabetes (TID) is a well-described condition and serious clinical obstacle. At present, the notion that early atherogenesis is largely dependent on sustained hyperglycemia remains in question. We hypothesize that an alteration in T lymphocyte homeostasis may result in early vascular inflammation, which might amplify subsequent blood vessel injury in euglycemia. A murine model of carotid arterial ligation was employed to induce neointimal hyperplasia (NIH) in C57/Bl6 (non-autoimmune) and non-obese diabetic (NOD) mice. Additionally, adoptive transfer of NOD splenocytes into immunodeficient NOD mice (NOD.scid) was undertaken to evaluate the influence of restored autoimmunity on NIH development. Interestingly, compared with C57/Bl6 mice, the NOD demonstrate a significant increase in neointimal area. Conversely, the NOD.scid mice (immunodeficient control) reveal almost no evidence of vascular injury. While evidence of early vascular inflammation can be detected in the injured NOD vasculature, uninjured contralateral vessels and those of the NOD.scid have minimal T cell infiltration. Following reconstitution of autoimmune responses via NOD splenocyte adoptive transfer, accelerated vascular pathology is restored. These observations suggest that autoimmunity, in the setting of impending hyperglycemia, may contribute to accelerated vascular inflammation and subsequent pathology.

Acute bone marrow stromal injury in the dog

A 5-year retrospective study of bone marrow reports was conducted to identify dogs with acute marrow stromal injury. Of 382 reports that were included in the study, acute stromal alterations were identified in 27 (7.1%). Disease conditions associated with these inflammatory changes included nonregenerative immune-mediated hemolytic anemia (IMA), systemic lupus erythematosus, immune-mediated thrombocytopenia, infectious diseases, drug treatments, and idiopathic conditions. Pathologic changes associated with acute stromal injury included coagulation-type necrosis, individual cell necrosis, dilated sinusoids, interstitial edema, hemorrhage, multifocal fibrin deposits, and multifocal neutrophilic infiltrates. Nonregenerative IMA tended to be associated with individual cell necrosis and evidence of vascular injury and acute inflammation. Infectious diseases tended to be associated with coagulation-type necrosis vascular injury and acute inflammation. Microabscesses were observed only in dogs with bacterial infections. Acute stromal injury associated with drug treatments were associated with coagulation-type necrosis but not with vascular injury or acute inflammation. The pattern of these changes may be useful in suggesting possible causes.

Duplex Evaluation of Trauma from Gunshot Wounds

Introduction Diagnosis and repair of arterial injury from penetrating trauma is critical because the lack of intervention can result in limb loss or death. Patients that have conspicuous arterial injuries can be explored and repaired in the operating room with or without preoperative diagnostic imaging. Patients without definite clinical evidence of vascular injury (i.e., hematoma, pulsatile mass, bruit, or pulse deficit) generally undergo angiography because of proximity of injury. Arteriography is an expensive and invasive procedure for patients; it carries some discomfort and has potential complications associated with its use. In our experience, ankle/brachial index (ABI) alone has not been a dependable study to rule out significant arterial injury of extremities. Color flow duplex imaging is a painless procedure, has no risk to the patient, is not as expensive as arteriography and is readily available in most institutions. We present two patients who had normal pulses and ABIs after gunshot wounds to extremities. Both patients had significant arterial injury detected by color flow duplex imaging as the initial diagnostic modality and subsequently proceeded on to arteriography based on the findings of the duplex studies. Conclusions The findings of the duplex imaging were in direct correlation with arteriography. These two cases demonstrate the sensitivity of color flow duplex ultrasonography to detect extremity arterial injuries in a community hospital.

Ultrastructural Study of the Vascular Endothelium of Patients with Spontaneous Rupture of Hepatocellular Carcinoma

Spontaneous rupture of hepatocellular carcinoma (HCC) is common in Asia and Africa, although the mechanism is unclear. In our previous study, we found that vascular injury exemplified by collagenase synthesis and collagen degradation in small arteries was related to the HCC rupture. In this study, transmission electron microscopy was used to study 22 specimens from ruptured HCC and non-ruptured HCC. In nine specimens of ruptured HCC, there was evidence of vascular injury with fewer cell junctions and larger fenestrae in vascular endothelial cells. The phenomenon of increased endothelial protein synthesis was also present. In the specimens of non-ruptured HCC, evidence of vascular injury was found in only two cases (p < 0.01). Fewer cell junctions and larger fenestrae could increase the permeability of the vascular wall. Increased protein synthesis in endothelial cells correlates with the phenomenon that more collagenase is expressed in these cells. The resulting breakdown of collagen could render the blood vessels weak; hence, these blood vessels are more prone to splitting/breakage. We conclude from our study that this vascular injury may result in HCC rupture.

Continued experience with physical examination alone for evaluation and management of penetrating zone 2 neck injuries: Results of 145 cases

Purpose: Our preliminary experience with physical examination alone in the evaluation of penetrating zone 2 neck injuries for vascular trauma was previously reported in 28 patients over a 2-year period (1991-1993). The purpose of the current study was to examine the results of this approach in a much larger group of patients over an 8-year period. Methods: The medical records for all patients admitted to our level I trauma center (all of them entered into our prospective protocol) between December 1991 and April 1999 with penetrating zone 2 neck trauma were reviewed for their initial presentation and any documented vascular injury. Results: A total of 145 patients made up the study group; in 30 of these patients, the penetrating trajectory also traversed zone 1 or 3. Thirty-one patients (21%) had hard signs of vascular injury (active bleeding, expanding hematoma, bruit/thrill, pulse deficit, central neurologic deficit) and were taken immediately to the operating room; 28 (90%) of these 30 patients had either major arterial or venous injuries requiring operative repair (the false-positive rate for physical examination thus being 10%). Of the 114 patients with no hard signs, 23 underwent arteriography because of proximity of the injury to the vertebral arteries or because the trajectory included another zone. Of these 23 arteriograms, three showed abnormalities, but only one required operative repair. This case had no complications relating to the initial delay. The remaining 91 patients with no hard signs were observed without imaging or surgery for a minimum of 23 hours, and none had any evidence of vascular injury during hospitalization or during the initial 2-week follow-up period (1/114; false-negative rate for physical examination, 0.9%). Conclusions: This series confirms the earlier report indicating that patients with zone 2 penetrating neck wounds can be safely and accurately evaluated by physical examination alone to confirm or exclude vascular injury. The missed-injury rate is 0.7% (1/145) with this approach, which is comparable to arteriography in accuracy but less costly and noninvasive. Long-term follow-up is needed to confirm this management option. (J Vasc Surg 2000;32:483-9.)

Is routine arteriography mandatory for penetrating injury to zone 1 of the neck? Zone 1 Penetrating Neck Injury Study Group.

Surgical dogma dictates that the evaluation of all penetrating zone 1 neck injuries must include arteriography to reliably exclude arterial injury requiring operation. This study was done to determine whether patients with normal findings at physical examination (PE) and on chest radiographs (CXR) really do require arteriography to identify occult, surgically important arterial injuries. All penetrating zone 1 neck injuries in five Level I trauma centers over a 10-year period were reviewed retrospectively. Data collected included demographics, results of PE, CXR findings, other diagnostic studies done, injuries identified, need for operation, and operative findings. Arterial injury was defined as any injury to the aorta or brachiocephalic, subclavian, vertebral, or carotid arteries found on arteriography, duplex, or at operation. Of 138 patients studied, there were 28 arterial injuries. Of the total group of 138 patients, 36 patients had normal findings at PE and on CXR. None of these 36 patients had an arterial injury. The negative predictive value of normal PE and CXR together is 100% in this series. Patients with penetrating wounds to zone I who have no evidence of vascular injury on PE and who have normal findings on CXR may not require routine arteriography. Further study is needed to confirm these findings.

The significance of carotid canal involvement in basilar cranial fracture.

Basilar cranial fractures have been associated with injury to the carotid artery. We sought to determine whether fracture through the carotid canal was a significant risk factor for carotid injury. A retrospective chart review was performed, and 230 patients with basilar cranial fractures were identified. Fifty-five of the 230 patients had visible fractures that extended through one or both carotid canals (CC fx group). Evidence for vascular injury, based on medical records, angiography, magnetic resonance imaging, and other studies, was compiled. The anatomic characteristics of the fractures were also noted and recorded. Ten patients in the CC fx group suffered vascular complications; for six of them, the complications were directly related to the intracranial carotid artery. This compares to four patients in the non-CC fx group with vascular complications (P < 0.005), only one of which was carotid-specific (P < 0.005). The most common site of fracture through the canal was at the junction of the lacerum and cavernous portions of the canal (the spheno-occipital suture) (62% of all carotid canal fractures occurred at that site); however, vascular injury was seen most often in patients who sustained fractures through the petrous segment (67% of carotid canal-specific injuries occurred in that group, and 25% of patients with petrous canal fractures suffered carotid injury, [P = not significant]). The mean Glasgow Coma Scale score and the mean age were both lower (P < 0.05) in the CC fx group. Vascular complications are more frequently observed after basilar cranial fractures when there is involvement of the carotid canal. The lacerum-cavernous junction, which is partly formed by the spheno-occipital suture, is the most frequently fractured segment of the carotid canal. Fracture through the petrous segment of the carotid canal is associated with a relatively high incidence of carotid injury. Fracture through the carotid canal may serve as an index of injury severity, because patients with these fractures suffered more severe head injuries.

Thromboxane and prostacyclin release after endotoxin infusion in the rat

To determine in the rat whether pulmonary artery hypertension accompanies thromboxane release, we sequentially monitored pulmonary and systemic artery pressures and cardiac output. We measured pulmonary and aortic plasma levels of TxB2 as well as 6-keto-prostaglandin F1 alpha (6-keto-PGF1 alpha) in awake unrestrained adult male Sprague-Dawley rats given a single infusion of endotoxin at the relatively high dose commonly administered to this endotoxin-resistant species. At 40 min after endotoxin infusion, both pulmonary and aortic TxB2 and 6-keto-PGF1 alpha levels increased nine-fold and seven-fold above baseline, respectively. In the pulmonary artery, 40 min after infusion, both mediator levels differed significantly from baseline (p less than 0.05), whereas in the aorta, because of marked variance in the response of different animals, only the 6-keto-PGF1 alpha levels achieved significance (p less than 0.05). These changes were associated with a fall in systemic blood pressure and cardiac output, but no demonstrable rise in pulmonary artery pressure (PAP). Despite ultrastructural evidence of vascular injury, these data indicate that in the rat thromboxane and prostacyclin release following a single infusion of endotoxin is not associated with pulmonary hypertension and that increased prostacyclin production may contribute to systemic hypotension.

Koebnerization as a cutaneous manifestation of immune complex—mediated vasculitis

Two unusual examples of the cutaneous manifestations of vasculitis are presented. In both cases lesions occurred on previously traumatized skin and on normal skin of the dependent areas. Lesional skin biopsy specimens obtained from the koebnerized sites and from the other dependent sites revealed evidence of vascular injury in both patients. A diagnosis of leukocytoclastic vasculitis was made in one patient and pityriasis lichenoides et varioliformis acuta in the other. Direct immunofluorescence microscopy of lesional skin specimens from both patients demonstrated dermal vascular immune deposits. Raji cell assay detected a significant elevation of circulating immune complexes in the serum of both patients. Neither koebnerizing leukocytoclastic vasculitis nor koebnerizing pityriasis lichenoides et varioliformis acuta has been reported previously.

Cardiac dysfunction during acute lung injury induced by oleic acid in dogs.

Circulatory abnormalities are common during the adult respiratory distress syndrome and contribute importantly to the high mortality seen with this illness, but what causes them is not well characterized. Oleic acid-induced acute lung injury is an experimental model of the human syndrome in which hemodynamic changes are also common. To characterize a possible link between lung injury and cardiac dysfunction in this model, we evaluated cardiac function in mongrel dogs after oleic acid administration. Stroke volume index decreased, the radionuclide ventriculographically determined ejection fraction decreased, and end-diastolic volume increased after oleic acid. These results suggested a decrease in myocardial contractility, a conclusion confirmed when other experiments demonstrated a consistent rightward displacement of the end-systolic pressure-diameter relationship after oleic acid. Histologic examination of the myocardium showed little evidence of vascular injury, and myocardial tissue wet-to-dry weight ratios were normal. Thus, although the pulmonary effects of oleic acid are due to microvascular injury, similar mechanisms are not responsible for the depression in myocardial contractility.

BLUNT TRAUMA TO THE THORACIC OUTLET AND ANGIOGRAPHY

When major injuries occur to the thoracic outlet, common practice is to obtain an arteriogram without other clinical evidence of vascular injury, because of the purported high association of thoracic outlet trauma and vascular injuries, including ruptured aortae. In order to evaluate this association, a review was undertaken of all patients admitted to a major hospital over 5.5 years who underwent angiography or other evaluative measures as a result of their thoracic outlet trauma. There were no great vessel or aortic injuries without overt clinical criteria. Angiography for aortic and great vessel injury is unnecessary unless there is a widened mediastinum or other overt clinical indications of vascular injury. Judicious use or avoidance of angiography is therefore encouraged for multiple reasons.

Vascular changes in leg trauma.

Fifteen patients with closed fractures of the distal tibia and fibula had marked elevation of initial compartment pressures. The pressures remained elevated for five days in the ten patients treated by cast and elevation. The pressures returned to normal within 24 hours in the five patients placed in a prototype water-jacketed boot which provides cooling and intermittent compression. Some patients exhibited arteriographic evidence of vascular injury.