Iatrogenic Arterial Injury Research Articles

Pseudoaneurysms of lower limb of orthopaedic traumatological origin: a literature review and our experience of 18 cases.

Arterial pseudoaneurysm is a rare yet potentially life-threatening complication that can arise as a late sequelae of penetrating injuries or orthopaedic procedures. We aim at sharing our institutional experience of managing 18 cases of lower limb arterial pseudoaneurysms in orthopaedic practice and to provide technical tips for emergency management of severe bleeding. A comprehensive literature review resulting from fractures and orthopaedic surgeries is also presented. The study group consisted mainly of male patients with a mean age of 48.5years. The mean duration between injury and pseudoaneurysm diagnosis was 86.7days. CT angiography and USG Doppler were the main diagnostic modality. Among the cases, five resulted from fracture fragments and 13 from iatrogenic injuries. Surgical interventions varied based on the artery involved and included excision and ligation, bypass grafting with dacron or vein graft, primary repair, and amputation in two cases. Complications included one patient with blowout at the anastomotic site and another case of deep infection. The literature review encompassed 108 cases of pseudoaneurysm of lower limb associated with fractures and iatrogenic injuries during orthopaedic procedures. Clinical manifestations varied widely which included painful swelling, pulsatility, bleeding, and neurological deficits. CT angiography was the most utilized diagnostic modality, while therapeutic embolization was the most common treatment method. Iatrogenic arterial injuries contributed to more than 60% of the cases as per the literature review. The most frequent mechanisms related to instrumentation were the placement of the third and fourth screws of the DHS plate, and the distal screw of a short nail in treating pertrochanteric fractures. This can be avoided by external rotation and abduction of the limb during distal screw insertion. A high index of clinical suspicion is needed especially when bleeding from the hardware site is noted. A swelling in the previously operated site should raise a suspicion of pseudoaneurysm and incision and drainage must be avoided without further imaging (Duplex USG or CT angiography). This study highlights the importance of cautious surgical techniques to minimize the occurrence of vascular injuries during orthopaedic surgeries.

New-generation single-layer PTFE-covered coronary stent for endovascular repair of iatrogenic arterial side-branch injury in non-coronary lesions for the RECOVER (REsults after percutaneous interventions with COVERed stents) Investigators

BackgroundThe incidence of iatrogenic injuries in peripheral arteries is increasing due to the expanding opportunities of managing various cardiovascular diseases by means of percutaneous intervention. Thus, endovascular repair with implantation of covered stent (CS) after vascular injury is gaining importance as an alternative to open surgery. In cases of smaller side-branch injuries, stenting of the main vessel with subsequent exclusion and sealing of the side-branch is associated with unfavourable revascularization rates and unpredictable ischemic complications in the corresponding supply area. ObjectiveThis study reports the procedural and clinical outcomes of patients with iatrogenic vascular side-branch injuries treated with coronary-CS directly at the site of injury. MethodsThis is a retrospective, multicentre registry study, including 40 patients with acute iatrogenic injuries of arterial side-branches undergoing implantation of single-layer polytetrafluorethylene (PTFE)-CS at 3 different centres in Europe between June 2014 and June 2023. Endpoints were procedural success, death, target vessel reintervention (TVR), bleeding and the need for surgical conversion. ResultsA total of 40 patients underwent implantation of single-layer PTFE-CS in the lower (97.5 %) and the upper limbs (2.5 %). The most common mechanisms were injuries after punctures, caused by needle and/or sheath (80 %), balloon-dilations (7.5 %) and during/after non-cardiac surgery (7.5 %). Procedural success was achieved in all cases (100 %). The rate of in-hospital mortality was 7.5 %. The median duration of hospitalization after the CS procedure was 4 days [2; 5.3]. At a median follow-up of 202.5 days [97.3–711.8], 36 patients (90 %) were alive and main vessel patency was 100 %. There were no cases of TVRs, bleedings or surgical conversions. Access-site related complications occurred in 5 % of all cases. ConclusionsIn this study, the use of new-generation single-layer PTFE-covered coronary stents in non-coronary side-branch lesions after iatrogenic arterial injury shows a high technical success rate and favourable clinical efficacy and safety.

Pediatric Limb Ischemia: Our Experience from a Tertiary Hospital in Oman

Introduction: Pediatric acute limb ischemia (PALI) is a consequence of sudden loss of blood flow to an extremity that can progress to irreversible ischemia if not promptly treated. This may unfortunately result in life-changing consequences which include limb loss, limb length discrepancy, emotional trauma, and or financial stress. Due to the rarity of this condition, and the lack of high-quality evidence, treatment strategies have largely been anecdotal or extrapolated from treatment of the adult patient. The article is a guide to improve overall functional outcomes and reduce morbidity of PALI. Methods: The authors retrospectively analysed patient data on the electronic patient record of the hospital between January 2021 and December 2023. The patients with PALI were divided into three broad categories: iatrogenic arterial injury managed with the best medical management, managed surgically; iatrogenic deep vein injury/thrombosis, and trauma. Results: A total of 13 patients were referred during the study period. 9 were male. 8 cases were line related, 2 trauma and 3 acute deep vein thrombosis [DVT]. Two patients succumbed prior to intervention. Eight patients were managed with best medical therapy, two surgically and one by endovascular means. Conclusion: Since experience worldwide is limited with PALI, we decided to share our experience and a propose comprehensive algorithm for the management of PALI emphasizing a multi-disciplinary team approach that we follow at our hospital. Early and decisive involvement of vascular surgeons, hematologists, intervention radiologists, and pediatric intensive care physicians is necessary to achieve the most favorable outcomes.

Clinical outcome of permanent femoral artery ligation in four dogs

AbstractFour dogs experienced intraoperative iatrogenic arterial injury during orthopaedic surgeries of the pelvic limb. After various haemostatic techniques failed, intraoperative haemostasis was achieved only by permanent ligation of the femoral artery. All dogs were re‐examined clinically and radiographically between 6 and 26 weeks postoperatively (short‐term follow‐ups). For the purpose of this study, three dogs were contacted for a long‐term re‐examination (orthopaedic and neurological) more than 2 years postoperatively (24–39 months), and their owners completed the Liverpool osteoarthritis in dog questionnaire. Visual gait analysis was scored subjectively (n = 3), and was recorded objectively using a pressure‐sensitive walkway (n = 2). No short‐ or long‐term complications related to the permanent femoral artery ligation were encountered, and limb function was normal for the dogs rechecked long‐term. Femoral artery ligation can be considered a last resort but safe salvage procedure in dogs with intraoperative arterial bleeding of the pelvic limb when standard haemostatic techniques have failed.

Type I Endoleak Following Covered Stent Graft Placement for Traumatic Subclavian Artery Pseudoaneurysm

AbstractSubclavian artery pseudoaneurysm is an uncommon entity caused by trauma or iatrogenic arterial injury. Endovascular management is the preferred treatment strategy but can be complicated by endoleaks. We report a case of type I endoleak occurring after endovascular covered stent placement to treat a traumatic pseudoaneurysm of proximal left subclavian artery.

Role Of Renal Artery Embolization In Treatment Of Iatrogenic Renal Bleeding.

To review institutional experience about the effectiveness and safety of percutaneous trans-arterial renal artery embolization in the treatment of iatrogenic renal bleeding. The prospective study was conducted from December 2019 to December 2021 at Ain Shams University Hospital and Kafrelsheikh University Hospital, Egypt, and comprised patients of either gender who underwent renal artery embolization for iatrogenic arterial renal bleeding caused by percutaneous nephrolithotomy, renal biopsy and percutaneous nephrostomy. Diagnostic renal angiography was done to detect pseudoaneurysm and arteriovenous fistula. Embolization was done with either micro-coils or glue. Success of the procedure was defined astotal occlusion of the bleeding artery proved by post-embolization angiogram. Of the 15 patients, 9(60%) were males and 6(40%) were females. The overall mean age was 35+/-14 years. Percutaneous nephrolithotomy was the main cause 8(53.3%), followed by renal biopsy 5(33.3%) and percutaneous nephrostomy 2(13.2%). There were 9(50%) cases of pseudoaneurysm and 6(40%) of arteriovenousfistula. Embolization was done with micro-coils in 5(33.3%) cases and with glue in 10(66.6%). The technical success rate was 15(100%). No major complicationsrequiring intensive care orsurgical intervention were encountered, and there was no significant differences in estimated glomerular infiltration rate or renal function after renal artery embolization (p>0.05). Percutaneous endovascular renal artery embolization was found to be a safe and effective technique in the management of iatrogenic renal arterial injury.

A single-center initial experience on laparoscopic pancreatic operation combined with hepatic arterial resection and reconstruction.

This study aims to summarize our single-center initial experience in laparoscopic pancreatic operation (LPO) combined with hepatic arterial resection and reconstruction, as well as to demonstrate the feasibility, safety, and key surgical procedure for LPO. We retrospectively analyzed 7 patients who had undergone LPO combined with hepatic arterial resection and reconstruction in our center from January 2021 to December 2022. The clinical data of these 7 patients were collected and analyzed. In our case series, two patients underwent passive arterial resection and reconstruction due to iatrogenic arterial injury, and five patients underwent forward arterial resection and reconstruction due to arterial invasion. The arterial anastomosis was successful in 5 cases, including 2 cases of end-to-end in situ and 3 cases of arterial transposition, and the vascular reconstruction time was 38.28 ± 15.32 min. There were two conversions to laparotomy. The postoperative recovery of all patients was uneventful, with one liver abscess (Segment 4) and no Clavien III-IV complications. We also share valuable technical feedback and experience gained from the initial practice. Based on the surgeon's proficiency in open arterial resection and reconstruction and laparoscopic technique. This study demonstrated the feasibility of total laparoscopic hepatic arterial resection and reconstruction in properly selected cases of arterial involvement or iatrogenic arterial injury. Our initial experience provides valuable information for laparoscopic pancreas surgery with arterial resection and reconstruction.

Endovascular Management of Iatrogenic Arterial Injuries after Orthopedic Surgery of the Lower Limb

PurposeTo evaluate the safety and effectiveness of embolization, and to identify the contributory factors of failures in patients treated for iatrogenic arterial injuries after orthopedic surgery of the lower limb. Materials and MethodsIn this retrospective study, data from patients treated from December 2008 to March 2022 for an arterial injury due to orthopedic surgery of the lower limb were analyzed from a single center. Demographic, clinical, and procedure-related data were collected. Perioperative and 30-day mortalities were estimated. Odds ratios and hazard ratios were calculated for several potential risk factors: age of >75 years, atherosclerosis, preexisting infection, urgency of surgery (trauma vs elective), previous surgery, multiple distant injuries, and multiple vascular supplies to the same injury. ResultsEighty-six procedures performed on 78 patients were included in the study. The rates of technical and clinical success were 100% and 92.3%, respectively. Six (7.7%) patients were retreated because of persistent bleeding. The perioperative mortality was 1.3%, and the 30-day mortality rate was 7.7%. The presence of multiple arterial supplies, multiple injuries, previous surgery, presence of atherosclerosis, or a preexisting musculoskeletal infection resulted in a higher risk of retreatment. ConclusionsEmbolization is safe and effective in the management of iatrogenic arterial injuries after orthopedic surgery. The number of involved vascular territories was the most critical factor in determining technical failure.

Neuromonitoring Guided Vessel Identification in Iatrogenic Arterial Injury During Meningioma Resection

ABSTRACT Neuromonitoring is commonly used in neurosurgery and allows intraoperative assessment of functional pathways in the brain during surgery. Monitoring alerts can guide surgical decision making in real-time allowing surgeons to mitigate or avoid potential iatrogenic injury and subsequent postoperative neurologic sequelae that may result from cerebral ischemia or malperfusion. Here we present a case of a patient undergoing a right pterional craniotomy for the resection of a tumor which crosses midline with multimodal intraoperative neuromonitoring including somatosensory evoked potentials, transcranial motor evoked potentials, and visual evoked potentials. During the final portion of tumor resection, arterial bleeding was noted of unknown origin shortly followed by loss of right lower extremity motor evoked potential recordings. Motor evoked potential recordings in the right upper, and left upper and lower extremities were stable, as well as all somatosensory evoked potentials and visual evoked potentials. This distinct pattern of right lower extremity motor-evoked potential loss suggested compromise of the contralateral anterior cerebral artery and guided the surgeons to a rapid intervention. The patient awoke from surgery with moderate postoperative weakness in the affected limb that resolved to preoperative status by postoperative day 2, and back to normal strength prior to three-month follow-up. In this case the neuromonitoring data suggested compromise to the contralateral anterior cerebral artery which guided the surgeons to investigate and identify the site of vascular injury. The present case reinforces the utility of neuromonitoring in emergent surgical situations to guide surgical decision making.

Emergency treatment for iatrogenic lumbar arterial injury occurred during posterior lumbar interbody fusion: a case report

An iatrogenic vessel injury occurring during lumbar fusion is a rare but potentially serious complication. In this case report, we present a case of hypovolemic cardiac arrest attributable to an iatrogenic lumbar artery injury that occurred during posterior lumbar interbody fusion (PLIF), which is difficult to diagnose using CECT. A 70-year-old woman underwent PLIF surgery in a primary hospital for the treatment of degenerative spondylolisthesis (L2–L5). During the procedure, she experienced a blood loss of 3 liters, which necessitated the transfusion of packed red blood cells (6 units, about 200–250 mL per unit), fresh frozen plasma (6 units, about 150–170 mL per unit). Despite the transfusions, her vital signs remained unstable, leading to her transfer to our hospital. Upon arrival at our facility, the patient went into cardiac arrest, but spontaneous circulation was successfully restored after two cycles of cardiopulmonary resuscitation. In the emergency department, her hemoglobin level was measured at 2.7 g/dL, platelet level at 56,000/µL, and prothrombin international normalized ratio at 3.56. CECT did not indicate any active bleeding. For the initial 2 hours, her vital signs remained stable with a blood pressure of 92/53 mmHg, heart rate of 104 bpm, respiratory rate of 22 bpm. However, her blood pressure suddenly dropped to 78/43 mmHg. Subsequent angiography revealed active bleeding from the right fourth lumbar artery, prompting the performance of embolization. Following the procedure, the patient’s vital signs stabilized, and she was discharged on the 16th day of hospitalization. Iatrogenic vessel injuries during PLIF may pose challenges in their detection using CECT, especially when extravasation is not definitively visible or when artifacts are created by metal implants. Therefore, it is advisable for emergency physicians to consider emergency angiography in the diagnosis and treatment of such vessel injuries.

Iatrogenic Renal Artery Injury in 90 Cases: Arteriographic Findings and Outcomes after Embolization for Bleeding

PurposeTo evaluate differences in arteriographic findings and outcomes after embolization among patients with a suspected iatrogenic renal arterial injury (IRAI). Materials and MethodsPatients at the authors’ institution who underwent renal arteriography for suspected IRAIs after partial nephrectomy, biopsy, or percutaneous access over a 20-year period were included. Records, imaging, and outcomes were reviewed. Data analysis was performed using the Fisher exact or Kruskal-Wallis test. ResultsNinety arteriograms were performed on 83 patients after partial nephrectomy (n = 32), biopsy (n = 27), or percutaneous access (n = 24), including for nephrostomy/ureterostomy and stone removal. The median number of days between the index procedure and arteriogram was highest (15 days) after partial nephrectomy and lowest (5 days) after biopsy (P = .0001). Embolization was performed during 76% of arteriograms. If prearteriographic imaging showed positive results for IRAIs, embolization was performed in 67% versus 33% if imaging showed negative results (P = .005). The transfusion rate was higher after biopsy than after partial nephrectomy or percutaneous access (P = .002). Acute kidney injury after arteriogram occurred in 7% of patients; however, all returned to baseline by 1 week. ConclusionsDespite the different mechanism of IRAIs in partial nephrectomy, biopsy, and percutaneous access, arteriographic findings and outcomes were overall similar among groups. Prearteriographic imaging can help identify IRAIs but cannot supersede the clinical judgment regarding indication for embolization. IRAIs can present acutely or after a long interim, although patients who underwent biopsy presented earlier and more frequently required a blood transfusion. IRAIs can be treated with embolization without permanent deleterious effects on renal function.

Successful thoracoscopic management of iatrogenic left subclavian arterial injury: a case report.

The subclavian artery at the thoracic outlet is in the deepest position of the thoracic cavity and is difficult to repair in this narrow space once injured, even if the surgery is converted to a thoracotomy. This article presents a successful left subclavian artery repair procedure at the thoracic outlet using a thoracoscopic approach, with a video demonstration, and describes its technical characteristics. The patient was planned for a left upper lobectomy through three-port thoracoscopic approach. Severe adhesions were found intraoperatively and an accidental left subclavian arterial injury occurred when dissecting the adhesions. We first clamped the proximal portion of the subclavian artery and then directly clamped the rupture site. Our first suture failed due to the limited suture angle and the mutual restriction between the needle holder and atraumatic vascular clamp. To freely control the needle holder, another assistant port was made in the seventh intercostal space (ICS). The arterial injury was finally successfully repaired using pledgetted suture. The operation time was 235 minutes and intraoperative blood loss was 800 mL. The pulsation of the left radial artery was normal postoperatively, and the patient was discharged on postoperative day 6. Appropriate strategies allow attempts to manage intraoperative hyperbaric arterial bleeding from the systemic circulation, such as bleeding caused by subclavian arterial injuries, by means of a thoracoscopic approach without conversion to thoracotomy.

Pseudoaneurysm of the popliteal artery. Complication of knee arthroscopic procedures. Case raport

A pseudoaneurysm refers to a defect in an arterial wall, which allows the communication of arterial blood with the ad­ja­cent extraluminal space. Blood extravasates out of the ar­te­ry, but is contained by surrounding soft tissue which forms a cavity or sac. Pseudoaneurysms are typically the result of traumatic arterial injury. With the increasing uti­li­sa­tion of percutaneous arterial interventions worldwide, iatrogenic arterial injury has become the predominant cause of pseudoaneurysm formation. The highest inci­dence of iatrogenic pseudoaneurysm formation is observed in the common femoral artery as a result of inadequate hae­mo­sta­sis of the arterial puncture site following catheterisation pro­cedures, followed by the popliteal artery. Patients with popliteal pseudoaneurysms typically present with pain and swelling of the affected area (calf), along with a palpable mass which may be pulsatile with a thrill or bruit. Small pseu­do­­aneurysms can resolve spontaneously without in­ter­ven­tion. Persistent pseudoaneurysms may increase and lead to complications related to compression of the vein, nerve and overlying tissues. This can lead to swelling of the legs, deep vein thrombosis, compressive neuropathy and skin necrosis. Although rare, pseudoaneurysms can spread and eventually rupture. Imaging is a mandatory part of the di­ag­nostic protocol for popliteal artery pseudoaneurysms. Dop­pler ultrasound, CT or MRI examinations performed with contrast and angiography are useful in determining pseudoaneurysmal masses. Doppler ultrasound is the most commonly chosen method for diagnosing pseu­do­aneu­rysms, with a sensitivity of 94% and a specificity of 97% in the detection of pseudoaneurysms. On Doppler ul­tra­sound, a pseudoaneurysm appears as a hypoechoic sac adjacent to the affected artery, with the color flux ob­served inside it. Computed tomography angiography is another effective way of diagnosis, especially in centers with­out easy access to vascular ultrasound services. It is also useful in cases where Doppler ultrasound findings are ambiguous or the anatomy is not well defined. Open sur­gi­cal treatment has been considered the gold standard for ia­tro­genic pseu­do­aneu­rysms because the arterial defect is per­ma­nent­ly repaired.

Percutaneous treatment of vascular access-site complications: a ten years\u2019 experience in two centres

BackgroundThe spread of percutaneous arterial catheterization in diagnostic and therapeutic procedures has led to a parallel increase of vascular access site complications. The incidence of these events is between 0.2–1%. A detailed analysis of injuries by type of procedure shows a higher incidence of injuries after therapeutic procedures (3%) than those observed for diagnostic ones (1%), due to the greater size of the vascular devices used and the necessity to frequently administer anticoagulant and antiplatelet therapy during procedures. The iatrogenic arterial injuries requiring treatment are the pseudoaneurysm, arteriovenous fistula, arterial rupture and dissection. Less frequent complications include distal embolization of the limbs, nerve damage, abscess and lymphocele.Moreover, the use of percutaneous vascular closure devices (VCD) has further expanded the types of complications, with an increased risk of stenosis, thrombosis, distal embolism and infection. Our work aims to bring the personal 10 years’ experience in the percutaneous treatment of vascular access-site complications.ResultsNinety-two pseudoaneurysms (PSA), 12 arteriovenous fistulas (AVF), 15 retrograde dissections (RD) and 11 retroperitoneal bleedings (RB) have been selected and treated. In 120/130 cases there were no periprocedural complications with immediate technical success (92.3%). Nine femoral PSA, treated with percutaneous ultrasound-guided thrombin injection, showed a failure to close the sac and therefore they were treated by PTA balloon inflation with a contralateral approach and cross-over technique. Only one case of brachial dissection, in which the prolonged inflation of the balloon has not led to a full reimbursement of the dissection flap, was then surgically repaired. At the 7 days follow-up, complications were two abscesses in retroperitoneal bleedings, treated by percutaneous drainage. At 3 months, acute occlusion of 3 covered femoral stents occurred, then treated by loco-regional thrombolysis and PTA. A total of 18 major complications was recorded at 2 years, with a complication rate at 2 years of 13.8%.ConclusionsThe percutaneous treatment of vascular access-site complications is the first-choice treatment. It represents a safe and effective option, validated by a high technical success rate and a low long-term complication rate, that allows avoiding the surgical approach in most cases.

Emergency management of iatrogenic arterial injuries with a low-profile balloon-expandable stent-graft: Preliminary results.

Endovascular treatment of arterial injuries with stent-graft is a reliable alternative approach in patients not suitable for embolization or at high risk for surgery. The aim of our study was to evaluate the efficacy and the safety of the BeGraft stent-graft, a low-profile balloon expandable covered stent, for emergency endovascular treatment of iatrogenic arterial injuries.Between August 2015 and September 2018, 34 consecutive patients (mean age 71 ± 12 years, 9 females) underwent implantation of BeGraft stent-grafts for iatrogenic arterial injuries (22 active bleedings, 11 pseudoaneurysms, and 1 enteric-iliac fistula). The primary endpoints were technical and clinical success and rates of major and minor complications. The secondary endpoint was the patency of the device during the follow-up. Imaging follow-up was performed by duplex ultrasound and/or computed tomography angiography (according to lesion site/target vessel), at 1-6-12-15 and 24 months.In all 34 patients (100%), the lesion or the defect was effectively excluded with a cumulative amount of 42 stent-grafts. The clinical success was documented in 30/34 patients (88.2%). Neither device- or procedure-related deaths, or major complications occurred. A minor complication was reported in 1 patient (2.9%), successfully treated during the same procedure. Thirty (88.2%) patients were available for a mean follow-up time of 390 ± 168 days (minimum 184, maximum 770), with no observed loss of patency, yielding a 100% Kaplan-Meier cumulative survival patency function. The percentage of patent patients was 30/30 at 6 months, 22/22 at 12 months, and 5/5 at 15 months.Endovascular treatment of iatrogenic arterial injuries with the BeGraft stent-graft is minimally invasive and effective, with good patency rate at midterm follow-up.

Iatrogenic intra-arterial injection in the upper limb: A pragmatic guide for the on-call vascular surgeon

Background: Peripheral venous cannulation is one of the most commonly performed procedures to establish venous access in the hospital setting. Inadvertent arterial cannulation is a rare event but can have serious consequences including ischemia and limb loss, especially if medication is administered through the device. Vascular surgeons should have an understanding of the management of this potential complication Methods: We reviewed the risk factors, mechanism, pathophysiology, and management options for inadvertent upper limb arterial cannulation and injection. Results: Inadvertent arterial cannulation and administration of medication has a reported incidence of 1 in 3440 cases. Several risk factors were identified including difficult venous access, difficulty in communication, and aberrant vascular anatomy. Both arterial injury from the misplaced cannula and injection of medication can cause ischemic events through a number of mechanisms. We recommend that patients sustaining an inadvertent arterial injury should have an urgent clinical assessment and be managed according to the degree of upper limb ischemia as per the Rutherford classification. We provide a pragmatic management algorithm to aid the vascular surgeon when encountering such a situation. Conclusion: Iatrogenic arterial injury is a rare but potentially serious complication of peripheral venous cannulation. Prompt recognition and management of ischemic complications is essential for favorable outcomes. Our pragmatic management guide should aid the vascular surgeon in managing this situation.

Toll-like receptor 2-deficiency on bone marrow-derived cells augments vascular healing of murine arterial lesions

AimsNeointimal hyperplasia contributes to arterial restenosis after percutaneous transluminal coronary angioplasty or vascular surgery. Neointimal thickening after arterial injury is determined by inflammatory processes. We investigated the role of the innate immune receptor toll-like receptor 2 (TLR2) in neointima formation after arterial injury in mice. Materials and methodsCarotid artery injury was induced by 10% ferric chloride in C57Bl/6J wild type (WT), TLR2 deficient (B6.129-Tlr2tm1Kir/J, TLR2−/−) and WT mice treated with a TLR2 blocking antibody. 21 days after injury, carotid arteries were assessed histomorphometrically and for smooth muscle cell (SMC) content. To identify the contribution of circulating cells in mediating the effects of TLR2-deficiency, arterial injury was induced in WT/TLR2−/−-chimeric mice and the paracrine modulation of bone marrow-derived cells from WT and TLR2−/− on SMC migration compared in vitro. Key findingsTLR2−/− mice and WT mice treated with TLR2 blocking antibodies exhibited reduced neointimal thickening (23.7 ± 4.2 and 6.5 ± 3.0 vs. 43.1 ± 5.9 μm, P < 0.05 and P < 0.01), neointimal area (5491 ± 1152 and 315 ± 76.7 vs. 13,756 ± 2627 μm2, P < 0.05 and P < 0.01) and less luminal stenosis compared to WT mice (8.5 ± 1.6 and 5.0 ± 1.3 vs. 22.4 ± 2.2%, both P < 0.001n = 4–8 mice/group). The phenotypes of TLR2−/− vs. WT mice were completely reverted in WT/TLR2−/− bone marrow chimeric mice (5.9 ± 1.5 μm neointimal thickness, 874.2 ± 290.2 μm2 neointima area and 2.7 ± 0.6% luminal stenoses in WT mice transplanted with TLR2−/− bone marrow vs. 23.6 ± 5.1 μm, 3555 ± 511 μm2 and 12.0 ± 1.3% in WT mice receiving WT bone marrow, all P < 0.05, n = 6/group). Neointimal lesions of WT and WT mice transplanted with TLR2−/− bone marrow chimeric mice showed increased numbers of SMC (10.8 ± 1.4 and 12.6 ± 1.4 vs. 3.8 ± 0.9 in TLR2−/− and 3.5 ± 1.1 cells in WT mice transplanted with TLR2−/− bone marrow, all P < 0.05, n = 6). WT bone marrow cells stimulated SMC migration more than TLR2-deficient bone marrow cells (1.7 ± 0.05 vs. 1.3 ± 0.06-fold, P < 0.05, n = 7) and this effect was aggravated by TLR2 stimulation and diminished by TLR2 blockade (1.1 ± 0.03-fold after stimulation with TLR2 agonists and 0.8 ± 0.02-fold after TLR2 blockade vs. control treated cells defined as 1.0, P < 0.05, n = 7). SignificanceTLR2-deficiency on hematopoietic but not vessel wall resident cells augments vascular healing after arterial injury. Pharmacological blockade of TLR2 may thus be a promising therapeutic option to improve vessel patency after iatrogenic arterial injury.

Pseudoaneurysm of Dorsalis Pedis Artery Following Lisfranc Surgery: A Rare Complication

Aneurysm and pseudoaneurysm of the dorsalis pedis artery remains to be rare vascular entities with a reported incidence of 0.5% of peripheral arterial aneurysms. Only, few cases were reported. The formation of pseudoaneurysm is commonly associated with fracture, laceration wound or iatrogenic arterial injury. An arterial injury that coincides with pseudoaneurysm can initially be missed due to lack of clinical findings. Prompt recognition remains paramount to reduce morbidity and mortality. Here, we present a rare complication of a commonly performed orthopaedic procedure in a young male who presented with painful swelling over left foot after he was involved in an industrial injury. He presented again with a pulsating mass over his left foot after 2 months post fixation surgery of a Lisfranc injury. He was treated conservatively with compression bandage and able to regain to his normal activity after the treatment initiated.

Arterial reconstruction due to intraoperative arterial injury or arterial tumor involvement during pancreatectomy-single centre experience in 35 cases

Background: The incidence of iatrogenic intraoperative arterial injury (AI) during pancreatectomy is not well described. Arterial resection and reconstruction (AR) due to arterial tumor involvement (ATI) is controversial. This study aims to evaluate the incidence of AI during pancreatectomy and the outcome of pancreatectomy with AR due to ATI or AI. Methods: All consecutive patients undergoing pancreatectomy between 2006 and 2016 were included. Results: Of a total of 1526 patients, AI was diagnosed in 13 patients (0.85 %). AI occurred in 10 of 922 pancreatoduodenectomies, 2 of 509 distal pancreatectomies (1 of 22 open, 1 of 488 laparoscopic), 1 of 43 total pancreatectomies, and 0 of 51 enucleations (1 open, 50 laparoscopic). AR was performed due to ATI in 22 patients and AI in 12 patients. AI was associated with aberrant arterial anatomy, peripancreatic inflammation or a combination of the two in all cases. Estimated blood loss for AR-ATI and AR-AI was median 900 ml and 1100 ml. Rate of severe complications (≥ Clavien grade 3) was 11/22 (50 %) and 6/13 (46 %). Ninety-day mortality was 4.5 % (1/22) in AR-ATI and 7.7 % (1/13) in AR-AI. Estimated median overall survival in patients with pancreatic and periampullary adenocarcinoma (n=15) undergoing AR due to ATI was 21 months. Conclusion: The incidence of AI during pancreatectomy was 0.85 %. AR due to ATI or AI is associated with a high rate of severe complications, but an acceptable mortality rate.

Case Report: Surgical Management of Iatrogenic Injury to Brachiocephalic Artery From Central Venous Cannulation

Background: Iatrogenic arterial injury of the brachiocephalic artery during central venous cannulation has rarely been reported [ [1] de Troia A. Tecchio T. Azzarone M. Biasi L. Piazza P. Franco Salcuni P. Endovascular treatment of an innominate artery iatrogenic pseudoaneurysm following subclavian vein catheterization. Vasc Endovascular Surg. 2011; 45: 78-82 Google Scholar ]. A multicentre retrospective study from 2008 estimated the incidence of large-bore catheter misplacement into an artery during central venous cannulation to be 1 in 1,800 [ [2] Guilbert M.-C. Elkouri S. Bracco D. et al. Arterial trauma during central venous catheter insertion: Case series, review and proposed algorithm. J Vasc Surg. 2008; 48: 918-925 Abstract Full Text Full Text PDF PubMed Scopus (189) Google Scholar ]. The morbidities of this complication include arterial dissection, haemothorax, and arteriovenous fistula.