Hematoma Rate Research Articles

Effect of Chronic Antiplatelet and Anticoagulant Medication in Neck Hematoma and Perioperative Outcomes after Carotid Endarterectomy

A retrospective analysis of neck hematoma, stroke, and mortality after symptomatic and asymptomatic carotid endarterectomy (CEA) was conducted, to determine the most appropriate perioperative medication for these patients. Thirty-day outcomes of moderate and severe neck bleeding were also investigated. Patients undergoing CEA in a Vascular Surgery department were analyzed (2015-2019). Preprocedure antithrombotic medication (from the 5 days prior to surgery) was identified. End point predictors were identified by univariate and multivariable analyses and adjusted for confounders. A total of 304 CEA were included. Almost half of the included patients (49.67%) were under low-dose aspirin, 17.55% other single antiplatelet agent, 12.59% dual antiplatelet therapy, 8.61% anticoagulation, and 10.92% no antithrombotic therapy. There was a 8.22% rate of important hematoma, including 4.93% severe (requiring surgical exploration) hematomas and a 30-day all-stroke incidence of 2.94% in symptomatic and 1.79% asymptomatic patients (P=0.51). When compared to aspirin, severe hematoma was more prevalent with single clopidogrel or triflusal (relative risk [RR] 4.25, P=0.11), dual antiplatelet group (RR 11.84, P=0.002), and anticoagulation (RR 8.604, P=0.02). Dual antiaggregation and anticoagulation did not confer postoperative stroke protection compared to single aspirin in either symptomatic or asymptomatic patients. Nonsignificant higher intrahospital mortality was noted in no medication, dual antiplatelet, and anticoagulation groups in contrast to aspirin. Severe neck bleeding was associated with increased congestive heart failure (9.26-fold, P=0.03) and longer hospital stay (11.20±24.69days vs. 3.18±4.79 with no bleeding, P<0.001), with a tendency for higher hospital readmission at 30 days (4.66-fold, P=0.13). Mortality and stroke rates were similar. Double antiaggregation and anticoagulation did not confer better perioperative outcomes after elective CEA in our study. These regimens were associated with an increased risk of neck hematoma, especially severe bleeding, with similar rates of neurologic events in both symptomatic and asymptomatic patients and no mortality benefit. Monotherapy with aspirin appears to be the safest perioperative antithrombotic regimen for elective CEA.

Safety and Efficacy of the Superior Gluteal Artery Perforator (SGAP) Flap in Autologous Breast Reconstruction: Systematic Review and Meta-Analysis

(1) Background: The superior gluteal artery perforator (SGAP) flap is a prominent technique for autologous breast reconstruction. Unlike other commonly used techniques, current literature on the safety and efficacy of the SGAP flap is heterogenous and limited. The aim of this article was to perform a systematic literature review and meta-analysis of postoperative outcomes and complications associated with SGAP flap autologous breast reconstructions. (2) Methods: A systematic literature search of multiple databases was performed using the PRISMA guidelines. We included articles evaluating SGAP flaps in autologous breast reconstruction. Outcomes and complications were recorded and analyzed. Proportions and their 95% confidence intervals (CIs) were calculated in a random-effects meta-analysis. (3) Results: Fourteen studies meeting inclusion criteria, representing a total of 667 SGAP flaps, were included. The total flap loss rate was 1% (95% CI 0-3%), partial flap loss rate was 1% (95% CI 0-3%), hematoma rate was 3% (95% CI 1-6%), emergent surgical re-exploration rate was 5% (95% CI 2-9%), and overall donor-site complications were 12% (95% CI 4-23%). (4) Conclusions: This systematic review and meta-analysis provide comprehensive knowledge on the efficacy and safety of the SGAP flap in autologous breast reconstruction. It demonstrates its overall safety and low complication rate, validating its important role as an effective option in breast reconstruction.

In-plane guided upper arm arteriovenous fistula cannulation with color ultrasound.

The blood vessel in the upper extremity arteriovenous fistula (AVF) is deep in the tissue, and cannulation in AVF is frequently associated with blood oozing, hematoma, or aneurysm. This study evaluated the performance of color ultrasound in-plane guided cannulation technique during upper extremity high-AVF cannulation in patients with hemodialysis. A total of 40 patients with hemodialysis who needed cannulation in upper extremity AVF were recruited in the study, and the patients were randomly divided into observation group and control group. Color Doppler ultrasound was used to guide cannulation in the observation group and in the control group blind cannulation method was applied. The success rate of one-time cannulation, the incidence of subcutaneous hematoma, oozing, and pain caused by incorrect fistula cannulation as well as the satisfaction score of the patients were compared to evaluate the effect and advantages of color ultrasound-guided cannulation. The one-time success rate of internal fistula cannulation in the observation group (98.71%) was significantly higher than that in the control group (88.27%). The incidence rates of hematoma, oozing, pain, and total failure events were significantly reduced in the observation group. The average satisfaction degree in the observation group was also significantly higher than that of the control group. Ultrasonic-guided cannulation effectively enhances the success rate of cannulation in upper extremity AVF, reduces the incidence of cannulation failures, and improves the satisfaction level in the patients.

Carotid artery stenting during endovascular thrombectomy for acute ischemic stroke with tandem occlusion: the Italian Registry of Endovascular Treatment in Acute Stroke.

The management of tandem extracranial internal carotid artery and intracranial large vessel occlusion during endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) has been under-investigated. We sought to investigate outcomes of AIS patients with tandem occlusion (TO) treated with carotid artery stenting (CAS) compared to those not treated with CAS (no-CAS) during EVT. We performed a cohort study using data from AIS patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke. Outcomes were 3months' mortality, functional outcome, complete and successful recanalization, any intracranial hemorrhage, parenchymal hematoma and symptomatic intracerebral hemorrhage. Among 466 AIS patients with TO, CAS patients were 122 and no-CAS patients were 226 (118 excluded). After adjustment for unbalanced variables, CAS was associated with a lower rate of 3months' mortality (OR 0.407, 95% CI 0.171-0.969, p = 0.042). After adjustment for pre-defined variables, CAS was associated with a lower rate of 3months' mortality (aOR 0.430, 95% CI 0.187-0.989, p = 0.047) and a higher rate of complete recanalization (aOR 1.986, 95% CI 1.121-3.518, p = 0.019), successful recanalization (aOR 2.433, 95% CI 1.263-4.686, p = 0.008) and parenchymal hematoma (aOR 2.876, 95% CI 1.173-7.050, p = 0.021). CAS was associated with lower 3months mortality (OR 0.373, 95% CI 0.141-0.982, p = 0.046) and higher rates of successful recanalization (OR 2.082, 95% CI 1.099-3.942, p = 0.024) after adjustment for variables associated with 3months' mortality and successful recanalization, respectively. Among AIS patients with TO, CAS during EVT was associated with a higher rate of successful reperfusion and a lower rate of 3months' mortality.

Complications associated with early cranioplasty for patients with traumatic brain injury: a 25-year single-center analysis.

Cranioplasty is a technically simple procedure, although one with potentially high rates of complications. The ideal timing of cranioplasty should minimize the risk of complications, but research investigating cranioplasty timing and risk of complications has generated diverse findings. Previous studies have included mixed populations of patients undergoing cranioplasty following decompression for traumatic, vascular, and other cerebral insults, making results challenging to interpret. The objective of the current study was to examine rates of complications associated with cranioplasty, specifically for patients with traumatic brain injury (TBI) receiving this procedure at the authors' high-volume level 1 trauma center over a 25-year time period. A single-institution retrospective review was conducted of patients undergoing cranioplasty after decompression for trauma. Patients were identified and clinical and demographic variables obtained from 2 neurotrauma databases. Patients were categorized into 3 groups based on timing of cranioplasty: early (≤ 90 days after craniectomy), intermediate (91-180 days after craniectomy), and late (> 180 days after craniectomy). In addition, a subgroup analysis of complications in patients with TBI associated with ultra-early cranioplasty (< 42 days, or 6 weeks, after craniectomy) was performed. Of 435 patients identified, 141 patients underwent early cranioplasty, 187 patients received intermediate cranioplasty, and 107 patients underwent late cranioplasty. A total of 54 patients underwent ultra-early cranioplasty. Among the total cohort, the mean rate of postoperative hydrocephalus was 2.8%, the rate of seizure was 4.6%, the rate of postoperative hematoma was 3.4%, and the rate of infection was 6.0%. The total complication rate for the entire population was 16.8%. There was no significant difference in complications between any of the 3 groups. No significant differences in postoperative complications were found comparing the ultra-early cranioplasty group with all other patients combined. In this cohort of patients with TBI, early cranioplasty, including ultra-early procedures, was not associated with higher rates of complications. Early cranioplasty may confer benefits such as shorter or fewer hospitalizations, decreased financial burden, and overall improved recovery, and should be considered based on patient-specific factors.

National randomized clinical trial on subdural drainage time after chronic subdural hematoma evacuation.

Placement of a subdural drain reduces recurrence and death after evacuation of chronic subdural hematoma (CSDH), but little is known about optimal drainage duration. In the present national trial, the authors investigated the effect of drainage duration on recurrence and death. In a randomized controlled trial involving all neurosurgical departments in Denmark, patients treated with single burr hole evacuation of CSDH were randomly assigned to 24 hours or 48 hours of postoperative passive subdural drainage. Follow-up duration was 90 days, and the primary study outcome was recurrent hematoma requiring reoperation. Secondary outcome was death. In addition, complications and length of hospital stay were recorded and analyzed. Of the 420 included patients, 212 were assigned 24-hour drainage and 208 were assigned 48-hour drainage. The recurrence rate was 14% in the 24-hour group and 13% in the 48-hour group. Four patients died in the 24-hour group, and 8 patients died in the 48-hour group; this difference was not statistically significant. The ORs (95% CIs) for recurrence and mortality (48 hours vs 24 hours) were 0.94 (0.53-1.66) and 2.07 (0.64-7.85), respectively, in the intention-to-treat analysis. The ORs (95% CIs) for recurrence and mortality per 1-hour increase in drainage time were 1.0005 (0.9770-1.0244) and 1.0046 (0.9564-1.0554), respectively, in the as-treated sensitivity analysis that used the observed drainage times instead of the preassigned treatment groups. The rates of surgical and drain-related complications, postoperative infections, and thromboembolic events were not different between groups. The mean ± SD postoperative length of hospital stay was 7.4 ± 4.3 days for patients who received 24-hour drainage versus 8.4 ± 4.9 days for those who received 48-hour drainage (p = 0.14). The mean ± SD postoperative length of stay in the neurosurgical department was significantly shorter for the 24-hour group (2 ± 0.9 days vs 2.8 ± 1.6 days, p < 0.001). No significant differences in the rates of recurrent hematoma or death during 90-day follow-up were identified between the two groups that randomly received either 24- or 48-hour passive subdural drainage after burr hole evacuation of CSDH.

Femoral Artery Closure Devices vs Manual Compression During Cardiac Catheterization and Percutaneous Coronary Intervention.

Femoral arterial access remains widely used despite recent increase in radial access for cardiac catheterization and percutaneous coronary intervention (PCI). Various femoral artery closure devices have been developed and are commonly used to shorten vascular closure times, with variable rates of vascular complications observed in clinical trials. We sought to examine the rates of contemporary outcomes during diagnostic catheterization and PCI with the most common femoral artery closure devices. We identified patients who had undergone either diagnostic catheterization alone (n = 14,401) or PCI (n = 11,712) through femoral artery access in the Indiana University Health Multicenter Cardiac Cath registry. We compared outcomes according to closure type: manual compression, Angio-Seal, Perclose, or Mynx. Access complications and bleeding outcomes were measured according to National Cardiovascular Data​Registry standard definitions. The use of any vascular closure device as compared to manual femoral arterial access hold was associated with a significant reduction in vascular access complications and bleeding events in patients who underwent PCI. No significant difference in access-site complications was observed for diagnostic catheterization alone. Among closure devices, Perclose and Angio-Seal had a lower rate of hematoma than Mynx. The use of femoral artery access closure devices is associated with a reduction in vascular access complication rates as compared to manual femoral artery compression in patients who undergo PCI.

Clinical Outcomes in Basal Ganglia Strokes Treated With Mechanical Thrombectomy

Background Basal ganglia infarcts are thought to carry worse clinical outcomes compared with other infarct patterns. We aimed to investigate whether pretreatment topographic infarct patterns including complete basal ganglia involvement versus other infarct patterns help predict mechanical thrombectomy outcomes. Methods This was a review of a prospectively collected database of consecutive mechanical thrombectomy patients with anterior circulation large vessel occlusion strokes between January 2014 and November 2018. Patients were categorized into the following 2 groups: (1) total basal ganglia (TBG) strokes defined as infarcts affecting both the caudate and lentiform nuclei regardless of cortical involvement and (2) other infarct patterns. Infarct location was assessed on preprocedure noncontrast computed tomography using an automated software (e‐ASPECTS). Baseline characteristics and outcome measures were compared. Results A total of 1011 patients were analyzed of which 234 (23.12%) had TBG strokes. Patients with TBG strokes were younger ( P =0.01); had higher National Institutes of Health Stroke Scale (NIHSS) ( P =0.006), lower e‐ASPECTS ( P &lt;0.001), and lower systolic blood pressure ( P =0.024); and had diabetes less often ( P =0.01). Baseline characteristics were otherwise comparable between groups. Involvement of the caudate or lentiform nucleus alone was observed in 237 (30.5%) and 21 (2.7%) patients, respectively, in the other infarct patterns group. No internal capsule involvement was detected in either group. There were no differences in terms of 90‐day functional outcomes whether dichotomized (modified Rankin Scale score≤2: TBG=44.6% versus other=50.1%; P =0.14) or looking at the entire spectrum of the scale (shift analysis; P =0.74). However, TBG strokes had significantly higher rates of any parenchymal hematomas (15.4% versus 8.2%; P =0.001), an association that held true in multivariable analysis (adjusted odds ratio, 2.57 [95% CI, 1.41–4.62]; P =0.002). Conclusions Despite increased rates of hemorrhagic transformation, ganglionic infarcts carry similar functional outcomes after mechanical thrombectomy compared with other stroke patterns.

Can prophylactic incisional negative pressure wound therapy Reduce Wound Complications After Inguinal Lymph Node Dissection for Melanoma? Results from a Randomized Controlled Trial

BackgroundInguinal lymph node dissection (ILND) is associated with a high complication rate. Retrospective studies suggest that incisional negative pressure wound therapy (iNPWT) might reduce complications, especially seroma, following ILND. MethodsThis was a prospective multicenter, randomized (1:1), open-labeled, parallel-group trial. Patients with macrometastic melanoma to the inguinal lymph nodes and eligible for ILND were randomized to receive either iNPWT for 14 postoperative days or conventional wound dressing. The primary outcome was seroma incidence. Secondary outcomes included surgical-site infection, wound rupture, wound necrosis, hematoma, rehospitalization and readmission rates between groups. All outcomes were registered 3 months after ILND and analyzed according to the intention-to-treat principle. ResultsThe trial was terminated early due to a low recruitment rate as a consequence of a change in the national treatment protocol, and the estimated sample size was not reached. Twenty patients were included and randomized in the study. The trial showed less seroma formation between the iNPWT 6/11 (55%) and control 7/9 (78%) groups; however, this was not statistically significant (p = 0.29). Similarly, there were no differences in the rates of surgical-site infection (p = 0.63), wound rupture (p = 0.19), wound necrosis (p = 0.82), hematoma (p = 0.19), reoperation (p = 0.82) or readmission (p = 0.34) between groups. ConclusionThere was a tendency toward fewer complications in the iNPWT group, however this trial was underpowered and could not confirm the hypothesis that iNPWT reduces complications after ILND. Future randomized controlled trials are required to fully evaluate the treatment potential of iNPWT. Trial registrationThe trial was prospectively registered at https://clinicaltrials.gov/ct2/show/NCT03433937.

Application of the dynamic needle tip positioning method for ultrasound-guided arterial catheterization in elderly patients: A randomized controlled trial.

BackgroundArterial cannulation in elderly patients is difficult because of age-related morphological changes. Applying dynamic needle tip positioning (DNTP) that guides the catheter to position inside the vessel sufficiently may aid in successful cannulation.MethodsThis prospective study enrolled patients aged over 70 years, who were scheduled for elective surgery under general anaesthesia with arterial cannulation. The patients were randomly assigned to the DNTP (group D, n = 76) or the conventional short-axis view(group C, n = 75) group. The arterial depth, diameter, and arterial conditions(calcification, segmental stenosis, and tortuosity) were evaluated using ultrasound, before puncture. We recorded the first attempt success, cannulation time, the number of attempts, and cannulation-related complications.ResultsA total of 151 patients were enrolled in this study. The first attempt success rate in group D was significantly higher than that in group C (89% versus 72%; P = 0.0168). The median cannulation time per last attempt in group D versus group C was 25 versus 30 sec(P = 0.0001), and the overall cannulation time was 25 versus 35 sec(P = 0.0001), respectively. Arterial cannulation per last attempt and overall cannulation time were shorter in group D. The number of attempts was higher in group C (P = 0.0038). The occurrence rate of hematoma was significantly lower in group D (16% versus 47%, relative risk = 3.0, P = 0.0001).ConclusionsThe DNTP method may improve the first attempt success rate of arterial cannulation and reduce complications in elderly patients over 70 years of age.

Antithrombotic Therapy and Hematoma Risk during Image-guided Core-Needle Breast Biopsy.

Background For image-guided core-needle breast biopsy (CNBB), it remains unclear whether antithrombotic medication should be withheld because of hematoma risk. Purpose To determine hematoma risk after CNBB in patients receiving antithrombotic medication and to stratify risk by antithrombotic type. Materials and Methods This HIPAA-compliant retrospective study included US-, stereotactic-, or MRI-guided CNBBs performed across six academic and six private practices between April 2019 and April 2021. Patients were instructed to continue antithrombotic medications, forming two groups: antithrombotic and nonantithrombotic. Hematomas were defined as new biopsy-site masses with a diameter of 2 cm or larger on postprocedure mammograms. Hematomas were considered clinically significant if management involved an intervention other than manual compression. Patient age, type of antithrombotic medication, practice type, image guidance modality, needle gauge and type, and outcome of pathologic analysis were recorded. Multivariable logistic regression analysis was used to analyze variables associated with hematomas. Results A total of 3311 biopsies were performed in 2664 patients (median age, 60 years; IQR, 48-70 years; 2658 women). The nonantithrombotic group included 2788 biopsies, and the antithrombotic group included 523 biopsies (328 low-dose aspirin, 73 full-dose antiplatelet drugs, 51 direct oral anticoagulants, 36 warfarin, 32 daily nonsteroidal anti-inflammatory drugs, three heparin or enoxaparin). The antithrombotic group had a higher overall hematoma rate (antithrombotic group: 49 of 523 biopsies [9.4%], nonantithrombotic group: 172 of 2788 biopsies [6.2%]; P = .007), but clinically significant hematoma rates were not different (antithrombotic group: two of 523 biopsies [0.4%], nonantithrombotic group: one of 2788 biopsies [0.04%]; P = .07). At multivariable analysis, age (odds ratio [OR], 1.02; 95% CI: 1.01, 1.03; P < .001), 9-gauge or larger needles (OR, 2.1; 95% CI: 1.28, 3.3; P = .003), and full-dose antiplatelet drugs (OR, 2.5; 95% CI: 1.29, 5.0; P = .007) were associated with higher hematoma rates. US guidance (OR, 0.26; 95% CI: 0.17, 0.40; P < .001) and 10-14-gauge needles (OR, 0.53; 95% CI: 0.36, 0.79; P = .002) were predictive of no hematoma. Conclusion Because clinically significant hematomas were uncommon, withholding antithrombotic medications before core-needle breast biopsy may be unnecessary. Postbiopsy hematomas were associated with full-dose antiplatelet drugs, patient age, and 9-gauge or larger needles. No association was found with other types of antithrombotic medication. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Chang and Yoen in this issue.

177. The influence of hospital type, insurance type and patient income on 30-day complication and readmission rates following lumbar spine fusion

177. The influence of hospital type, insurance type and patient income on 30-day complication and readmission rates following lumbar spine fusion

987 Protocol Driven Reduction of Haematoma Following Symptomatic Carotid Endarterectomy (CEA) – a Prospective Cohort Study

Abstract Aim Stroke is the third leading cause of death in developed nations and the leading cause of long-term disability. Carotid artery stenosis accounts for 20 to 30% of ischaemic strokes. Carotid Endarterectomy, has proven highly effective in preventing the development of strokes, TIAs and reducing death among patients with symptomatic carotid artery stenosis of 50–99%. The most common complication of CEA is wound haematomas. This study evaluates a protocol driven haemostasis pathway aimed to address the findings of a recent QI project that identified a significantly high neck haematoma rate as well as a high return to theatre rate for the complication. Method A prospective cohort outcome study between June 2019 and June 2020 was conducted, with the introduction of this stepwise pathway introduced as a quality improvement measure. This was implemented at the end of successful patch closure, for each CEA. Results Post-CEA haematoma rates decreased from 7% to 3.6%. Return to theatre rates reduced from 6% to 0.9% with no increase in peri-operative stroke rates. Conclusion Our protocol appears to reduce post-CEA haematoma rates. Return to theatre rates had also dropped without an increase in peri-operative stroke rates despite using protamine and tranexemic acid when needed.

159. Impact of smoking status on early and late outcomes after adult spinal deformity surgery

159. Impact of smoking status on early and late outcomes after adult spinal deformity surgery

25. Perioperative complications associated with epidural injections followed by cervical decompression and fusion

<h3>BACKGROUND CONTEXT</h3> Cervical epidural steroid injections (CESIs) are widely used to alleviate pain caused by degenerative diseases of the cervical spine. However, some data suggest a potential link between CESIs and infection rates following fusion surgeries. No prior studies have assessed the association between CESI and other postoperative outcomes such as hematomas, revision rates, or wound complications following anterior cervical discectomy and fusion (ACDF) and posterior cervical decompression and fusion (PCDF). Therefore, using a national dataset, we aimed to explore whether an association exists between preoperative CESIs and a variety of serious complications following ACDF and PCDF surgery. <h3>METHODS</h3> In this retrospective cohort study, we queried the IBM MarketScan national claims dataset (after IRB approval) and included adult patients who had undergone inpatient or outpatient ACDF or PCDF surgery due to disc herniation, stenosis, radiculopathy, spondylosis, or myelopathy from January 2014 to September 2017. Current procedural terminology codes were used to identify patients who received a CESI within one year prior to their surgery. Multivariable logistic regression measured the association between preoperative CESI and postoperative rates of 90-day infection, hematoma, wound complications, revision surgery, or combined complications (the former first three complications). We report odds ratios (OR) and 95% confidence intervals (CI). <h3>RESULTS</h3> Among 44,777 ACDF patients, 31.2% (n=13,950) received a preoperative CESI. For PCDF, 3,284 patients underwent the surgery of which 22.3% (n=734) received a preoperative CESI. The median time from most recent CESI to ACDF surgery is 76 days (interquartile range 41-144 days) and 95 days (interquartile range 49-176 days) for PCDF. Among ACDF patients, preoperative CESI was associated with lower odds of developing a hematoma following ACDF (OR 0.60; 95% CI 0.37-0.99; p=0.0453); no significant associations existed for the other outcomes including infection (OR 0.98; 95% CI 0.77-1.26; p=0.8846), revision surgery (OR 0.94; 95% CI 0.71-1.23; p=0.6300), wound complications (OR 0.92; 95% CI 0.71-1.17; p=0.4865) or combined complications (OR 0.88; 95% CI 0.73-1.07; p=0.1904). In the PCDF cohort, no significant associations existed between preoperative CESI and post-PCDF infection (OR 1.26; 95% CI 0.82-1.95; p=0.2962), revision surgery (OR 1.96; 95% CI 0.91-4.18; p=0.0842), wound complications (OR 1.11; 95% CI 0.71-1.72; p=0.6608) or combined complications (OR 1.14; 95% CI 0.78-1.68; p=0.4929). <h3>CONCLUSIONS</h3> Our study is the first to assess a broad complication profile that includes hematoma rates, infection rates, revision rates, and wound complications following ACDF and PCDF surgeries. We found no association between preoperative CESI and the aforementioned complications following ACDF and PCDF which supports first-hand clinical outcomes. Future work will aim to delineate the role of timing of CESI before ACDF and PCDF surgery, and the impact of quantity of CESIs on complication risks. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

P33. Incidence, risk factors and clinical outcomes of cervical hematoma: an analysis from the Michigan Spine Surgery Improvement Collaborative registry

<h3>BACKGROUND CONTEXT</h3> Postoperative hematoma following anterior cervical spine surgery is an uncommon but potentially fatal complication. Persistent bleeding resulting in significant hematoma displaces the larynx and trachea resulting in swallowing difficulties or airway obstruction. Due to its low incidence, risk factors and clinical outcomes data are limited. From a large database, the authors sought to identify some common characteristics in patients who developed hematoma and evaluate their clinical outcomes after undergoing anterior cervical spine surgery. <h3>PURPOSE</h3> From a large database, the authors sought to identify some common characteristics in patients who developed hematoma and evaluate their clinical outcomes after undergoing anterior cervical spine surgery. <h3>STUDY DESIGN/SETTING</h3> Ambispective (retrospective/prospective)/Multicenter collaborative. <h3>PATIENT SAMPLE</h3> Patients undergoing anterior cervical spine surgery. <h3>OUTCOME MEASURES</h3> Hematoma incidence, PROMIS-PF score, other postoperative complications. <h3>METHODS</h3> The Michigan Spine Surgery Improvement Collaborative (MSSIC) is a statewide quality improvement initiative. Anterior cervical cases in MSSIC registry from 2014-2018 were identified and divided into two groups: Nonhematoma or Hematoma. Chi-square and t-test analyses were done to compare the two groups in terms of demographics, surgical characteristics, patient reported outcomes (baseline and postoperative PROMIS-PF score) and other postoperative symptoms or complications. All analyses were performed by using SAS 9.4. <h3>RESULTS</h3> Of the 9,958 cases, postoperative hematoma occurred in 114 (1.1%). Hematoma was associated with male gender (1.6% vs 0.7%, p .10 for all). A greater percentage of patients in the hematoma group reported dysphagia (6.9% vs 29.8%, p .05). <h3>CONCLUSIONS</h3> Postoperative hematoma after anterior cervical surgery was rare (1.1%). It was associated with male gender, increasing age, preoperative anticoagulation, prior spine surgery, inpatient procedures and surgeries involving C3-C5 and C3-C6. Hematoma was significantly associated with the adverse outcomes of dysphagia, prolonged hoarseness, and weakness - though PROMIS scores showed no difference at follow-up. Hematoma after anterior cervical surgery is rare but a serious complication. Our large database review revealed several interesting risk factors associated with hematoma. Procedures involving C3-C5 and C3-C6 had the highest rate of hematoma compared to more caudal surgeries. Difficulties with exposure as well as vascular anatomy in the upper cervical spine, the cricothyroid arteries bilaterally, could explain this finding. Thorough visual inspection to ensure hemostasis is obtained prior to closure is essential. Hematoma, if left unrecognized, can swiftly develop, and put patients at significant risk for life threatening airway obstruction or great vessel compression. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Testosterone Pellet Use in Transgender Men.

We assessed the efficacy and short-term adverse effects of testosterone pellet use in transgender men to broaden therapeutic options. We conducted a retrospective study of 30 transgender men who started testosterone pellets between 2018 and 2020. Testosterone pellets were started at dosages 675-825 mg per cycle and dose was adjusted according to testosterone levels obtained 1 to 6 months post-testosterone pellet insertion. Pharmacokinetics of testosterone pellet in transgender men was similar to those in cisgender men. Total testosterone levels reached a peak in 1 month and remained in the therapeutic range for ∼4 months in the range of 300-800 ng/dL. After switching over to testosterone pellets, 100% of patients continued to achieve amenorrhea and deepening of their voice. Most of the patients noticed increased hair growth in androgen-dependent regions (96.3%) and improved libido (70%). Adverse events were notable for a rate of polycythemia that was unexpectedly high at 46.67%. Pellet extrusion was found in 13.33% of patients. There was a low rate of pellet site hematoma (6.67%) and cellulitis (3.33%). No thromboembolic or cardiovascular events occurred in any of the patients. This study reveals that testosterone pellets are a reasonable alternative to other testosterone modalities in transgender men but would use caution in patients with a history of polycythemia or higher risk for thromboembolic events.

SP11.9 Balancing Risk of Haematoma and Venous Thrombosis in VTE Prophylaxis for Breast Cancer Surgery: A Systematic Review and Meta-Analysis

Abstract Introduction Venous thromboembolism (VTE) is a largely preventable cause of morbidity and mortality in post-operative patients, however Guidelines for VTE prophylaxis in breast cancer surgery are not well-established. Methods A comprehensive search was undertaken of all studies that described the role of VTE prophylaxis in breast cancer surgery. Comparative studies that reported on postoperative outcomes between patients who received VTE prophylaxis (prophylaxis) and those who did not (no prophylaxis) were included in the analysis. A meta-analysis using random-effects model was used to analyze key outcomes, with data presented as odds ratio (OR). Results A total of 2470 patients from 6 studies were included in this study. Of these patient, 60.9% (n: 1504) received prophylaxis. The haematoma rate in this study is 0.05% (n: 133). The incidence of haematoma was significantly associated with the use of prophylaxis (6.85% versus 3.11%, p: 0.001). Surgical intervention for haematomas was also significantly associated in this group (3.15% versus 0.83%, p: 0.004). However there was no difference in VTE events between both groups (0.26% versus 0.36%, p: 0.88). Conclusion The use of VTE prophylaxis in breast cancer surgery is associated with increased haematomas without any benefit in preventing venous thromboembolic events. Further studies that examine the use of risk assessment tools for VTE prophylaxis in high risk patients may be beneficial.

Application of VSD technique in adults with chronic osteomyelitis of the extremities combined with soft tissue defects.

To investigate the clinical application of vacuum sealing drainage (VSD) in chronic osteomyelitis of the extremities combined with soft tissue defects in adults. This study retrospectively included 32 adult patients with clearly diagnosed chronic osteomyelitis of the extremities combined with local soft tissue defects, and the trauma was covered by VSD after debridement, osteotomy, and vancomycin-laden bone cement filling of the occupancy, and the trauma was covered by selecting a suitable flap transfer repair according to the site and extent of the soft tissue defect after the trauma condition was suitable, and the secondary trauma was taken from the abdominal full-thickness skin free skin slice graft, according to whether the skin graft area was performed. The skin flap hematoma and infection rate, as well as the skin flap survival rate and implant fixation time were compared and analysed between the two groups. The primary outcome is the implant fixation time, and the secondary outcome is the skin fragment survival rate. In 32 patients, VSD was performed on the bone cement surface to cover the trauma, and 33.2 to 39.8kPa continuous vacuum sealing drainage was set. The average VSD time duration before soft tissue coverage was 47.87 ± 23.14 days, and the average number of VSD use was 7.18 ± 3.23. The use of VSD before soft tissue coverage did not cause complications such as negative pressure could not be maintained, vacuum sealing drainage was not smooth, skin blistering, trauma. Among the 32 patients, 12 cases of soft tissue coverage were followed by trauma free skin grafting with packing + VSD, and 20 cases were fixed with packing alone, and the duration of continuous packing and fixation of free skin pieces in the VSD group was significantly less than that in the control group (P=.006). The survival rate was significantly higher than that of the control group (P=.019). VSD in adult patients with chronic osteomyelitis of the extremities combined with soft tissue defects can effectively improve the trauma condition, provide the possibility of second-stage soft tissue coverage, and significantly shorten the preparation time for soft tissue coverage. In addition, when soft tissue coverage trauma is performed, VSD combined with skin graft packing technique can significantly improve the survival rate of skin pieces, shorten the time of skin graft fixation.

The Role of Early Superficial Temporal to Middle Cerebral Artery Bypass Revascularization Surgery in Middle Cerebral Artery‐Territory Strokes: A Systematic Review Study

Background To systematically summarize and critically review the available literature regarding the functional outcome of the urgent superficial temporal artery to the middle cerebral artery (MCA) bypass surgery in stroke patients associated with MCA lesions. Methods The current systematic review was conducted and reported using the Preferred Reporting Items for Systematic Reviews and Meta‐Analysis statement. Medline (PubMed), ISI Web of Science, Scopus, and google scholar (manually searches) were systematically searched up to August 2021. The eligibility criteria were defined as all the patients who had MCA‐territory strokes due to MCA/intradural internal carotid artery lesions that underwent same‐admission superficial temporal artery‐MCA bypass surgery. The strokes with cervical internal carotid artery and anterior cerebral artery lesions/strokes were excluded. The checklists produced by the US National Heart Lung and Blood Institute were used for quality assessment. Demographic variables, clinical findings, National Institutes of Health Stroke Scale scores, the time interval between symptoms to surgery, imaging results, endovascular treatments, surgical notes, mortality rate, follow‐up findings, modified Rankin scale scores, and all reported medical records were extracted and analyzed with SPSS software (ver. 23). P values ≤0.05 were considered meaningful. Results The initial search yielded 3050 records, and 13 articles met the inclusion criteria and entered this systematic review. A total of 165 patients were pooled for data analysis. Nine studies had data regarding neurological deficits before and after surgery. Except for 5 patients, the National Institutes of Health Stroke Scale score after the operation was the same or better than the preoperative score. Eleven out of 17 patients in 3 studies showed early neurological improvement (a decrease in National Institutes of Health Stroke Scale score of ≥4 points at 3 days) after bypass surgery. Functional outcome was stated in 10 studies. Overall, a good functional outcome (modified Rankin scale=0–2) was achieved in 9 out of 21 (42.1%) patients at discharge and in 44 out of 59 (74.5%) patients at 3 months follow‐up. Lower age was associated with favorable outcomes. Long‐term graft patency was excellent in 99.5% of patients. Postoperative hematoma and mortality (all noncranial) rates were 3% and 3.6%, respectively. Conclusion The current study suggests that early superficial temporal artery‐MCA revascularization should be considered an available option in younger patients (&lt;60‐year‐old) with MCA territory strokes who fail medical treatment.