Iliac Artery Injury Research Articles

Endovascular Versus Open Repair in Adolescent Patients With Difficult-to-Access Vascular Injuries

IntroductionManagement of subclavian artery injuries (SAI) and iliac artery injuries (IAI) in adolescent trauma patients poses a considerable challenge due to their complex anatomical locations. The aim of our study was to determine the association between the injury mechanism and type of repair with the outcomes of patients with traumatic SAI and IAI. MethodsIn this retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program database2017-2020, adolescent (<18 y) patients with SAI and IAI undergoing either endovascular or open repair were included. Patients were stratified by mechanism (blunt versus penetrating) and type of repair (endovascular [E] versus open [O]) and compared. Outcomes measured were mortality and major complications. Multivariable logistic regression analyses were performed. ResultsOver 4 y, 170 pediatric patients were identified, of which 73 (43%) sustained an SAI and 97 (57%) had IAI. The mean age was 15 and 79% were male. Overall, 39% were managed endovascularly. Both groups had comparable median injury severity score (E: 23 versus O: 25, P = 0.278). For patients with blunt injury (n = 60), the type of repair was neither associated with major complications (E: 39% versus O: 33%, P = 0.694) nor mortality (E: 2.6% versus O: 4.8%, P = 0.651). For patients with penetrating injuries (n = 110), the endovascular repair had significantly lower morbidity (19% versus 41%, P = 0.034) and mortality (3.7% versus 21%, P = 0.041). On multivariable logistic regression, endovascular repair was identified as the only modifiable risk factor associated with reduced mortality (adjusted odds ratio: 0.201, 95% confidence interval [0.14-0.76], P = 0.038). ConclusionsDifficult-to-access vascular injuries result in significant morbidity and mortality. Endovascular repair was found to be the only modifiable factor associated with decreased mortality of patients with penetrating injury, whereas the type of repair was not associated with mortality in those with blunt injury.

Assessment of the Therapeutic Effectiveness of Glutathione-Enhanced Mesenchymal Stem Cells in Rat Models of Chronic Bladder Ischemia-Induced Overactive Bladder and Detrusor Underactivity.

Overactive bladder (OAB) and detrusor underactivity (DUA) are representative voiding dysfunctions with a chronic nature and limited treatment modalities, and are ideal targets for stem cell therapy. In the present study, we investigated the therapeutic efficacy of human mesenchymal stem cells (MSCs) with a high antioxidant capacity generated by the Primed Fresh OCT4 (PFO) procedure in chronic bladder ischemia (CBI)-induced OAB and DUA rat models. Sixteen-week-old male Sprague-Dawley rats were divided into three groups (sham, OAB or DUA, and stem cell groups; n=10, respectively). CBI was induced by bilateral iliac arterial injury (OAB, 10 times; DUA, 30 times) followed by a 1.25% cholesterol diet for 8 weeks. Seven weeks after injury, rats in the stem cell and other groups were injected with 1×106 PFO-MSCs and phosphate buffer, respectively. One week later, bladder function was analyzed by awake cystometry and bladders were harvested for histological analysis. CBI with a high-fat diet resulted in atrophy of smooth muscle and increased collagen deposits correlating with reduced detrusor contractility in both rat models. Arterial injury 10 and 30 times induced OAB (increased number of non-voiding contractions and shortened micturition interval) and DUA (prolonged micturition interval and increased residual volume), respectively. Injection of PFO-MSCs with the enhanced glutathione dynamics reversed both functional and histological changes; it restored the contractility, micturition interval, residual volume, and muscle layer, with reduced fibrosis. CBI followed by a high-fat diet with varying degrees of arterial injury induced OAB and DUA in rats. In addition, PFO-MSCs alleviated functional and histological changes in both rat models.

Statin administration ameliorates ischemia-induced overactive bladder with improvement of blood flow and anti-inflammatory effects in rats.

Statins are widely used to treat dyslipidemia and have been shown to reduce the risk of ischemic heart disease and cerebrovascular disease. The effects of statins on ischemia-induced overactive bladder (OAB) and the associated mechanisms were investigated in a rat model of chronic pelvic ischemia. A pelvic ischemia model was created by iliac arterial injury (AI) and a high-fat diet using male Sprague-Dawley rats. Rats were assigned to 3 groups: control group, AI group, and AI + statin group. The control group underwent sham operation and was fed a normal diet. The AI group underwent AI surgery and was fed a high-cholesterol diet. The AI + statin group was administered a statin for 4 weeks. Cystometry was performed for 8 weeks after surgery. Blood flow was evaluated by laser meter. Thickness of the iliac arteries was measured, and microvascular density in the lamina propria was evaluated by immunostaining for CD31. Expressions of inflammatory cytokines in the bladder were measured by real-time PCR. Cystometry showed a significantly shorter voiding interval and lower bladder capacity in the AI group than in the control group. The AI + statin group showed improvement of these findings. The AI group showed decreased bladder blood flow, increased iliac arterial wall thickening, and decreased microvascular density compared to the control group. Statin administration improved blood flow. Iliac arterial wall thickening was suppressed, and microvascular density was increased by statin administration, though not significantly. Real-time PCR showed significantly higher expressions of inflammatory cytokines (IL-6, IL-8, and TNF-α) in the AI group than in the control group, and IL-6 and IL-8 expressions were lower in the AI + statin group than in the AI group. The present results suggest that statins are effective in OAB caused by arteriosclerosis and ischemia. The mechanism of their effects involves improved bladder blood flow and decreased bladder inflammation.

Lymphadenectomy before and after radical cystectomy: does this affect the radicality? A prospective randomized comparative study

PurposeTo compare the oncological outcome of performing ePLND before or after RC in 200 patients in a prospective randomized manner.Materials and methodsFrom January 2014 to December 2019, 200 patients with T2-T3b N0M0 BCa were included in the current study after signing an informed consent. Patients were divided into two groups, 100 in each one. Group I underwent ePLND before RC, whereas group II underwent ePLND after RC. Postoperative evaluation included clinical, laboratory, and radiographic studies.ResultsPatients’ characteristics were comparable between both groups. The mean operative time excluding that of urinary diversion was significantly shorter in group II than in group I (p = 0.01). The mean number of LNs removed was 25 ± 6 in group I and 32 ± 8 in group II (p = 0.141). Intraoperative complications occurred in four patients in the form of external iliac artery and vein injury [two in each group (p = 0. 245)]. Postoperative complications were comparable between both groups with no statistically significant difference (p = 0.375). Oncological failure occurred in 28 patients [16 (17.6%) in group I and 12 (22%) in group II (p = 0.389)].ConclusionsEPLND before and after RC has comparable oncological outcomes. The stage of the disease, the time since the first diagnosis till RC and the surgeon experience in performing meticulous ePLND are more important. In absence of oncological superiority, the timing of ePLND should be judged according to the patient-related factors to facilitate safe RC with minimal morbidity.

A case of hip joint disconnection caused by iatrogenic external iliac artery injury

A case of hip joint disconnection caused by iatrogenic external iliac artery injury

V03-09 MANAGEMENT OF INTRAOPERATIVE VASCULAR INJURIES IN UROLOGIC SINGLE-PORT OR MULTI-PORT ROBOTIC SURGERY

You have accessJournal of UrologyCME1 Apr 2023V03-09 MANAGEMENT OF INTRAOPERATIVE VASCULAR INJURIES IN UROLOGIC SINGLE-PORT OR MULTI-PORT ROBOTIC SURGERY Anh Nguyen, David Ali, Benjamin Rudnick, Rogerio Huang, Mubashir Shabil Billah, and Mutahar Ahmed Anh NguyenAnh Nguyen More articles by this author , David AliDavid Ali More articles by this author , Benjamin RudnickBenjamin Rudnick More articles by this author , Rogerio HuangRogerio Huang More articles by this author , Mubashir Shabil BillahMubashir Shabil Billah More articles by this author , and Mutahar AhmedMutahar Ahmed More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003241.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: There are many challenges to managing vascular injuries during robotic urologic surgeries. These include limited exposure due to the small field, inability to quickly expand the surgical field with retractors and additional personnel, inability manually palpate or apply manual pressure over a broad area, and reliance on a limited array of robotic instruments. Other challenges include the limited field of vision of the robotic camera, as well as reliance on insufflation to maintain adequate visualization. Consultant surgeons may not have significant experience with using the robot. These all can translate into longer operative times for repair of vascular injuries with resultant blood loss. We sought to share insights on how a robotic surgeon may handle repairing a vascular injury. METHODS: Three robotic multi- and single-port operative cases with vascular injuries were examined. Operative strategy was analyzed and discussed. RESULTS: A single-port robotic nephroureterctomy was done on a 68 year-old female with past history of endometrial cancer, hysterectomy with lymph node dissection, and radiation to the pelvis. A common iliac vein injury was incurred during dissection of the distal ureter and was repaired using robotic 4th arm to clamp the injured vessel, strategic use of ROSI suction, and non-absorbable 4-0 suture. A multi-port robotic radical prostatectomy was done on a 63 year-old male with history of Gleason 4+3 prostate cancer with inadvertent injury of the external iliac artery. A combination of robotic bulldog clamps, assistant suction and non-absorbable 4-0 suture was used to successfully repair the injury. Lastly, a multi-port robotic adrenalectomy was done for a 48 year-old female with a 6.5 cm adrenal mass with invasion into the IVC. Repair of the IVC was done with a combination of 4th arm and bulldog clamps, vessel loop traction, and non-absorbable 4-0 suture. CONCLUSIONS: Strategies to robotically repair inadvertent vascular injuries during urologic surgery require strategic use of the 4th robotic arm, assistant- or robotically-applied clamps, and assistant instruments to free up working arms. Non-absorbable suture should be readily available. Closure of large blood vessels require releasing clamps momentarily before closure to avoid air embolus. Maximal visualization can be achieved using the zoom features of the robotic camera and its ability to discriminate fine detail. Maintaining composure with frequent and adequate communication with anesthesia and intensive care teams is vital in safely managing vascular injuries. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e248 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Anh Nguyen More articles by this author David Ali More articles by this author Benjamin Rudnick More articles by this author Rogerio Huang More articles by this author Mubashir Shabil Billah More articles by this author Mutahar Ahmed More articles by this author Expand All Advertisement PDF downloadLoading ...

Discussion.

Journal of the American College of Surgeons 236(4):p 759-761, April 2023. | DOI: 10.1097/XCS.0000000000000601

Case report: Resuscitative endovascular balloon occlusion after iatrogenic injury of the common iliac artery during neurosurgical dorsal lumbar microdiscectomy.

This case report describes resuscitative endovascular balloon occlusion (REBOA) of the aorta in a patient with life-threatening iatrogenic bleeding of the right common iliac artery during elective dorsal lumbar spine surgery. REBOA is an emergency procedure for temporary intra-aortic balloon occlusion being increasingly reported and published since its inauguration in 1954. The interdisciplinary management of hemorrhage and technical notes for a successful REBOA procedure will be presented. A 53-year-old female patient was admitted to the neurosurgery clinic suffering from left-sided L5 radiculopathy. During surgery, the anterior longitudinal ligament was perforated and an arterial vessel was lacerated. The patient became hemodynamically unstable demanding prompt supine repositioning and cardiopulmonary resuscitation (CPR). REBOA enabled cardiovascular stabilization after 90 min of CPR and laparotomy with vascular reconstruction and contributed to the survival of the patient without major clinical deficits. The patient was discharged from the ICU after 7 days. Resuscitative endovascular balloon occlusion of the aorta is an emergency procedure to control life-threatening hemorrhage. REBOA should be available on-scene and applied by well-trained vascular surgery personnel to control vascular complications or extend to emergency laparotomy and thoracotomy with aortic cross-clamping in case of in-hospital non-controllable hemorrhages. In case of ongoing CPR, we recommend surgical groin incision, open puncture of the pulseless common femoral artery, and aortic balloon inflation in REBOA zone I. Hereby, fast access and CPR optimization for heart and brain perfusion are maintained. Training for REBOA is the decisive factor to control selected cases of in-house and outpatient massive arterial abdominal bleeding complications.

Role of Endovascular Stenting in Patients with Traumatic Iliac Artery Injury.

Common and external iliac artery injuries (IAI) portend significant morbidity and mortality. The goal of this study was to examine the impact of mechanism of injury and type of repair on outcomes and identify the optimal repair for patients with traumatic IAI using a large, national dataset. Patients undergoing operative repair for IAI were identified from the Trauma Quality Improvement Program database during a 5-year timespan, ending in 2019. Age, sex, race, severity of injury, severity of shock, type of iliac repair (open or endovascular), mechanism, morbidity and mortality were recorded. Patients with IAI were stratified by both type of repair and mechanism and compared. Multivariable logistic regression analysis was used to identify independent predictors of mortality. Operative IAI was identified in 507 patients. Of these injuries, 309 (61%) were penetrating and 346 (68.2%) involved the external iliac artery. The majority of patients were male (82%) with a median age and ISS of 31 and 20, respectively. Endovascular repair was performed in 31% of cases. For patients with penetrating injuries, the type of repair impacted neither morbidity nor mortality. For blunt-injured patients, endovascular repair was associated with lower morbidity (29.3% vs 41.3%; p = 0.082) and significantly reduced mortality (14.6% vs 26.7%; p = 0.037) compared with the open-repair approach. Multivariable logistic regression identified endovascular repair as the only modifiable risk factor associated with decreased mortality (odds ratio 0.34; 95% CI 0.15 to 0.79; p = 0.0116). Traumatic IAI causes significant morbidity and mortality. Endovascular repair was identified as the only modifiable predictor of decreased mortality in blunt-injured patients with traumatic IAI. Therefore, for select patients with blunt IAIs, an endovascular repair should be the preferred approach.

Endovascular Treatment for Vascular Injuries of the Extremities

Vascular injuries of the extremities are associated with a high mortality rate. Conventionally, open surgery is the treatment of choice for peripheral vascular injuries. However, rapid development of devices and techniques in recent years has significantly increased the utilization and clinical application of endovascular treatment. Endovascular options for peripheral vascular injuries include stent-graft placement and embolization. The surgical approach is difficult in cases of axillo-subclavian or iliac artery injuries, and stent-graft placement is a widely accepted alternative to open surgery. Embolization can be considered for arterial injuries associated with active bleeding, pseudoaneurysms, and arteriovenous fistula and in patients in whom embolization can be safely performed without a risk of ischemic complications in the extremities. Endovascular treatment is a minimally invasive procedure and is useful as a simultaneous diagnostic and therapeutic approach, which serve as advantages of this technique that is widely utilized for vascular injuries of the extremities.

Impact of Ischemia Duration on Lower Limb Salvage in Combat Casualties.

The 6-hour threshold to revascularization of an ischemic limb is ubiquitous in the trauma literature, however, contemporary evidence suggests that this threshold should be less. This study aims to characterize the relationship between the duration of limb ischemia and successful limb salvage following lower extremity arterial trauma. This is a cohort study of the United States and UK military service members injured while serving in Iraq or Afghanistan between 2003 and 2013. Consecutive patients who sustained iliac, femoral, or popliteal artery injuries, and underwent surgery to attempt revascularization, were included. The association between limb outcome and the duration of limb ischemia was assessed using the Kaplan-Meier method. One hundred twenty-two patients (129 limbs) who sustained iliac (2.3%), femoral (56.6%), and popliteal (41.1%) arterial injuries were included. Overall, 87 limbs (67.4%) were successfully salvaged. The probability of limb salvage was 86.0% when ischemia was ≤1 hour; 68.3% when between 1 and 3 hours; 56.3% when between 3 and 6 hours; and 6.7% when >6 hours ( P <0.0001). Shock more than doubled the risk of failed limb salvage [hazard ratio=2.42 (95% confidence interval: 1.27-4.62)]. Limb salvage is critically dependent on the duration of ischemia with a 10% reduction in the probability of successful limb salvage for every hour delay to revascularization. The presence of shock significantly worsens this relationship. Military trauma systems should prioritize rapid hemorrhage control and early limb revascularization within 1 hour of injury.

MP49-16 IMPAIRED UROTHELIAL BARRIER FUNCTION INDUCED LOWER URINARY TRACT DYSFUNCTION BY PROTEASE-ACTIVATED RECEPTER 2 ACTIVATION

You have accessJournal of UrologyCME1 May 2022MP49-16 IMPAIRED UROTHELIAL BARRIER FUNCTION INDUCED LOWER URINARY TRACT DYSFUNCTION BY PROTEASE-ACTIVATED RECEPTER 2 ACTIVATION Hidenori Akaihata, Yusuke Hakozaki, Hiroki Natsuya, Tomoyuki Kumekawa, Shunsuke Yoshioka, Hitomi Imai, Akifumi Onagi, Kanako Matsuoka, Tomoyuki Koguchi, Junya Hata, Yuichi Sato, Masao Kataoka, and Yoshiyuki Kojima Hidenori AkaihataHidenori Akaihata More articles by this author , Yusuke HakozakiYusuke Hakozaki More articles by this author , Hiroki NatsuyaHiroki Natsuya More articles by this author , Tomoyuki KumekawaTomoyuki Kumekawa More articles by this author , Shunsuke YoshiokaShunsuke Yoshioka More articles by this author , Hitomi ImaiHitomi Imai More articles by this author , Akifumi OnagiAkifumi Onagi More articles by this author , Kanako MatsuokaKanako Matsuoka More articles by this author , Tomoyuki KoguchiTomoyuki Koguchi More articles by this author , Junya HataJunya Hata More articles by this author , Yuichi SatoYuichi Sato More articles by this author , Masao KataokaMasao Kataoka More articles by this author , and Yoshiyuki KojimaYoshiyuki Kojima More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002624.16AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Recently, attention has focused on the association between urothelial barrier dysfunction and lower urinary tract dysfunction (LUTD). Uroplakin (UP) is critical to normal urothelial barrier function. Some studies reported that UPs defects lead to abnormal voiding patterns. It was also reported that impairing UP II causes mast cell infiltration in the bladder and that mast cell contributed to bladder hyperactivity. Mast cell tryptase (MCT) can regulate neuronal activity by cleaving protease-activated recepter 2 (PAR2), which is expressed on C-fiber. On the other hands, the mechanisms underlying LUTD caused by chronic ischemia are not completely known. This study aimed to investigate the effects of chronic ischemia on UPs and mast cell in the bladder using a rat model of chronic bladder ischemia (CBI). METHODS: Adult male Sprague-Dawley rats (16 weeks old) were divided into two groups (control and CBI; n=10 each). The CBI group received balloon endothelial injury of bilateral iliac arteries and a 2% cholesterol diet for 8 weeks to induce chronic ischemia. The control group received regular diet for 8 weeks. After monitoring urine output for 24 h, bladders were harvested. Bladder was processed for immunohistochemical staining and methylene blue staining. We used western blotting to measure expressions of UPs(UP Ia, UP Ib, UP II, UP III) in the bladder of this rat model to examine urothelial barrier function. The expression of MCT and PAR2 were also measured to evaluate C-fiber activation by mast cell. RESULTS: Metabolic cage studies showed that mean voided volumes were significantly smaller in the CBI (1.46±0.33 ml) than in the control (1.01±0.21 ml; P=0.001). In western blot analysis, UP II expression was significantly decreased (P=0.011) in the CBI compared with the control. With immunohistochemical staining, UP II-positive cells are located mostly. The percentage of UP II-positive cells on urothelium was significantly lower in the CBI (63.0±0.11%) than in the control (92.1±0.1%, P<0.001). The expression of MCT (P=0.024) and PAR2 (P=0.021) were significantly increased in the CBI compared with the control in western blot analysis. The methylene blue staining showed the number of mast cell was significantly more in the CBI than in the control (P=0.034). CONCLUSIONS: Chronic ischemia might impair urothelial barrier function through reduced expression of UP II in urothelium. Urothelial barrier dysfunction contributed to mast cell infiltration and increased PAR2 on C-fiber, resulting PAR2 activation by MCT. The PAR2 activation may induce LUTD by stimulating C fiber in rat model of chronic bladder ischemia. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e860 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hidenori Akaihata More articles by this author Yusuke Hakozaki More articles by this author Hiroki Natsuya More articles by this author Tomoyuki Kumekawa More articles by this author Shunsuke Yoshioka More articles by this author Hitomi Imai More articles by this author Akifumi Onagi More articles by this author Kanako Matsuoka More articles by this author Tomoyuki Koguchi More articles by this author Junya Hata More articles by this author Yuichi Sato More articles by this author Masao Kataoka More articles by this author Yoshiyuki Kojima More articles by this author Expand All Advertisement PDF DownloadLoading ...

Preliminary Experience With the Human Acellular Vessel: A Descriptive Case Series Detailing Early Use of a Bioengineered Blood Vessel for Arterial Repair

An infection-resistant, immediately available conduit for trauma and urgent vascular reconstruction remains a critical need for successful limb salvage. While autologous vein remains the gold standard, vein-limited patients and size mismatch are common issues. The Human Acellular Vessel (HAV) (Humacyte, Inc., Durham, NC) is a bioengineered conduit with off-the-shelf availability and resistance to infection, ideal characteristics for patients with challenging revascularization scenarios. This report describes HAV implantation in patients with complex limb-threatening ischemia and limited conduit options who may have otherwise faced limb loss. The Food and Drug Administration (FDA) expanded-access program was used to allow urgent implantation of the HAV for arterial reconstruction. Electronic medical records were reviewed with extraction of relevant data including patient demographics, surgical implantation, patency, infectious complications, and mortality. The HAV was implanted in 8 patients requiring vascular reconstruction. Graft or soft tissue infection was present in 2 patients. One patient with severe penetrating pelvic injury had 4 HAV placed to repair bilateral external iliac artery and vein injuries. There was 1 technical failure due to poor outflow, 2 patients died unrelated to HAV use, and 5 lower extremity bypasses maintained patency at an average of 11.4 months (range: 4-20 months). No HAV infectious complications were identified. This report is the first United States series describing early outcomes using the HAV under the FDA expanded-access program for urgent vascular reconstruction. The HAV demonstrates resistance to infection, reliable patency, and offers surgeons an immediate option when confronted with complex revascularization scenarios. Assessment of long-term outcomes will be important for future studies.

Outcomes in Blunt vs Penetrating Pelvic Vascular Injuries.

The purpose of this study is to determine if there is a difference in outcomes for patients with blunt and penetrating vascular injuries of the pelvis. Data were abstracted from the Trauma Quality Improvement Program database from 2011 to 2015. Patients >18 years with hypogastric, iliac, uterine, or ovarian arterial or venous injuries were included. Individuals with an AIS head or chest score >3 were excluded. Of the 2559 patients included, the mean age was 43 years (±19), 75.25% were male, and 32.6% had a comorbidity. 64.9% presented with blunt injury (mean ISS of 23 (±12)). 74.9% experienced a complication. The median hospital length of stay (LOS) and ICU LOS were 10days and 4 days, respectively. 6.7% had an adverse discharge. Mortality occurred in 8.3%. On bivariate analysis, patients who sustained blunt trauma were older (51 vs 31years), female (32.7% vs 10.1%), had a higher ISS (25.71 vs 17.65), and had a longer hospital LOS (16.65 vs 13.88). Patients with penetrating trauma had an increased chance of complications (78.4% vs 73.0%) and mortality (10.7% vs 7.0%). Multivariate analysis revealed in patients with blunt injuries have more complications (OR: 1.950 CI: 0.886-4.291 P = .097), a lower ISS (OR: 0.919, CI: 0.908-0.930, P < .001, were more likely to have an adverse discharge (OR: 2.05, CI: 1.62-2.60, P = .000), and had a higher risk of mortality (OR: 4.08 CI: 2.78-6.41 P < .000). Patients with blunt pelvic vessel injuries are at risk for an increased number of complications and have a higher risk of mortality. Those who survive are more likely to have an adverse discharge.

Real World Experience with the Human Acellular Vessel: A Bioengineered Implant for Arterial Repair that Expands Limb Salvage Options

INTRODUCTION AND OBJECTIVES METHODS The Food and Drug Administration (FDA) expanded-access program was used to allow urgent implantation of the HAV for arterial reconstruction. Electronic medical records were reviewed with extraction of relevant data including patient demographics, surgical implantation, patency, infectious complications and mortality. RESULTS The HAV was implanted in 10 patients requiring vascular reconstruction (Table 1). Graft or soft tissue infection was present in 4 patients. One patient with severe penetrating pelvic injury had four HAV placed to repair bilateral external iliac artery and vein injuries (Figure 1). There was 1 technical failure due to poor outflow, 2 patients died unrelated to HAV use, and 7 lower extremity bypasses maintained patency at an average of 9.1 months (range 1-20 months). No HAV infectious complications were identified. CONCLUSIONS This report is the first US series describing compassionate use of the HAV under the FDA expanded-access program for end-stage limb salvage. The HAV demonstrates resistance to infection, reliable patency, and offers surgeons an immediate option when confronted with difficult revascularization scenarios. The Food and Drug Administration (FDA) expanded-access program was used to allow urgent implantation of the HAV for arterial reconstruction. Electronic medical records were reviewed with extraction of relevant data including patient demographics, surgical implantation, patency, infectious complications and mortality. The HAV was implanted in 10 patients requiring vascular reconstruction (Table 1). Graft or soft tissue infection was present in 4 patients. One patient with severe penetrating pelvic injury had four HAV placed to repair bilateral external iliac artery and vein injuries (Figure 1). There was 1 technical failure due to poor outflow, 2 patients died unrelated to HAV use, and 7 lower extremity bypasses maintained patency at an average of 9.1 months (range 1-20 months). No HAV infectious complications were identified. This report is the first US series describing compassionate use of the HAV under the FDA expanded-access program for end-stage limb salvage. The HAV demonstrates resistance to infection, reliable patency, and offers surgeons an immediate option when confronted with difficult revascularization scenarios.

Routine Procedure Getting Complicated: Iliac Artery Injury during Herniated Disc Surgery.

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A single-center retrospective analysis of 77 traumatic arterial injuries of lower extremities

Objective: To analyze the treatment and clinical prognosis of lower extremity arterial injury caused by trauma. Methods: The clinical data of 77 patients with traumatic lower extremity arterial injury admitted to Department of Vascular Surgery,Yichang Central People's Hospital from January 2013 to June 2021 were collected retrospectively. There were 65 males and 12 females, with an average age of 47.4 years (range: 7 to 75 years). Among the 77 patients, 56 cases (72.7%) had open injury and 21 cases (27.3%) had closed injury. Iliac artery was injured in 9 cases (11.7%), common femoral artery in 7 cases (9.1%), superficial femoral artery in 1 case (1.3%), popliteal artery in 11 cases (14.3%) and inferior knee artery in 49 cases (63.6%). The treatment methods and clinical effects were analyzed. Results: One case with pelvic fracture combined the internal iliac artery injury and 1 case with multiple injuries involving the common femoral artery died of circulatory failure before surgery. Seventy-five cases received vascular-related operations, including arterial ligation in 24 cases, arterial reconstruction in 40 cases, stent graft implantation in 1 case, primary amputation in 2 cases, and arterial embolization in 8 cases. The overall mortality rate was 6.5% (5/77), all of which were closed injuries. Except for 2 cases who died before surgery, 3 cases with pelvic fracture combined the internal iliac artery injury died of multiple organ failure after internal iliac artery embolization. There were 8 cases received amputation (10.4%, 8/77), 5 cases with closed injury and 3 cases with open injury. In addition to 2 cases with primary amputation, 6 cases underwent secondary amputation due to ischemia-reperfusion injury after revascularization (4 cases with popliteal artery injury and 2 cases with subpatellar artery injury). The average followed-up time was 17 months (range: 2 months to 8 years). One patient with femoral artery injury underwent autologous great saphenous vein bypass, and lower limb artery CT angiography was re-examined 6 months after the operation, and 30% distal anastomotic stenosis was found. Ankle brachial index<0.8 was found in two patients 1 year after popliteal artery repair, but none of the patients had intermittent claudication symptoms, and no further intervention was performed. Five patients suffered delayed healing due to severe lower limb injury, fracture and skin injury. Among them, 2 cases had poor wound healing at the stump of amputation, which gradually healed 3 to 5 months after several debridements. The other 3 vascular injury combined with tibial fracture patients had delayed tibial healing after surgery, but no symptoms of vascular ischemia occurred. All the other patients recovered well and no other serious complications occurred. Conclusions: The proportion of death and disability in patients with lower limb artery injury caused by trauma is high. Active and orderly surgical repair according to the site and type of injury can reduce the mortality, save the function of the affected limb, and promote the healing of injury.

595 Penetrating Pelvic Trauma from a Crossbow Bolt: An Unusual Choice of Weapon

Abstract Introduction The crossbow was a popular weapon in medieval times due to their relative ease of use and accuracy but was superseded by firearms around the 16th century. Today, it is legal for adults in the UK to own a crossbow without a licence. Case Report A young adult male victim was brought to a Major Trauma Centre with a single lower left quadrant penetrating wound caused a crossbow bolt that was self-removed immediately after the injury. A 2.5cm entry wound was present with no exit wound. The patient was haemodynamically unstable on arrival and was transferred to theatre without imaging within 16 minutes of arrival. The main operative findings were multiple small bowel serosal tears, a full thickness small bowel injury with no contamination and a left external iliac artery injury with active bleeding which were all repaired primarily. The post-operative recovery course included occlusive left cephalic and antecubital vein thrombi and an extensive non-occlusive left common femoral vein thrombus treated with anticoagulant therapy but was otherwise unremarkable. He was discharged 10 days later with no lasting sequelae at 6-week follow up. Discussion This case highlights a rare but important and likely underreported modality of penetrating injury. Crossbow bolts have low kinetic energy compared to bullets but high penetrative force, thus little energy is transferred to surrounding tissues. Hence the main injuries caused by crossbow bolts are due to direct damage to structures they come into contact with. Although rare, trauma surgeons should be aware of the pattern of injury caused by crossbows.

V–A ECMO管理中にカニュレーション部位の血種形成に伴い送血管が血管内から逸脱したと推定された2例(Two cases considered to be the accidental removal of an arterial cannula caused by a subcutaneous hematoma around the cannulation site during veno–arterial extracorporeal membrane oxygenation)

要旨Veno–arterial extracorporeal membrane oxygenation（V–A ECMO）症例においてカニューラ関連の合併症の頻度は少なくない。我々はV–A ECMOを装着中にカニューラ関連の出血性合併症により心静止に至ったが救命できた2症例を経験したので報告する。症例1は難治性心室細動の47歳男性で，症例2は心原性および敗血症性ショックに伴う循環不全が進行した感染性心内膜炎の38歳女性。2症例ともV–A ECMOを装着中に送血管刺入部の腫脹と出血を生じた後，急速にV–A ECMOが維持できなくなり波形上心静止となった。送血管の血管内からの逸脱と考え，別ルートによるV–A ECMOの再確立後に腫脹側の動脈修復術を施行した。症例1は外腸骨動脈修復術のみで出血制御できたが，症例2は子宮動脈仮性瘤からの出血を伴っており，同部の経カテーテル的塞栓術を要した。送血管刺入部位の出血，腫脹を伴う出血性合併症は致死的になる可能性があり，その早期認知と対応は重要である。

Reoperative Anterior Lumbar Spine Access is Feasible and Safe

During the past two decades, the number of anterior lumbar spine reconstructions has increased significantly, as has the need for revisions and treatment of adjacent levels. We sought to determine the feasibility of reoperative anterior lumbar spine exposure. We performed a retrospective analysis of patients who had undergone repeat anterior extraperitoneal exposure of the lumbar spine from January 2009 to March 2021. Cases were excluded if reoperation had occurred within 1 month of the index procedure or if the reoperation had used a lateral approach. The demographic data and details on the operative procedure were analyzed. During the study period, 6130 procedures for anterior, oblique, or lateral exposure of the lumbar spine were performed. Within this cohort, 137 anterior reoperations were performed on 135 patients (mean age, 55.7 years; range, 19-83 years). The mean body mass index was 25.7 kg/m2 (range, 17-43 kg/m2). Most reoperations were remote from the index disc level (61%). The main indications for reoperation were adjacent level disease (n = 84), failed artificial disk repair (n = 25), and nonunion (n = 16). The approach was via the contralateral retroperitoneal space in 74, ipsilateral in 61, both sides in 1, and retro- and transperitoneal in 1. The median estimated blood loss for the 61 procedures performed without concomitant posterior reconstruction was 150 mL (range, 10-2050 mL). The procedure was aborted in seven cases (5%) because of the intraoperative anatomic findings. The levels successfully treated were L2-L3 in 16, L3-L4 in 26, L4-L5 in 30, L5-S1 in 88, and L6-S1 in 1. Artificial disk repair was performed at 33 levels and fusions at 128 levels. Two minor ureteral injuries occurred. Twenty venous injuries (15%) were primarily repaired. One patient required a venous stent for iatrogenic stenosis. Two internal iliac artery injuries were treated with ligation or repair. No patient died. Reoperative anterior spine exposure was successful in 95% of cases with relatively low morbidity and no mortality. Primary exposure of the L5-S1 level should be performed in the right retroperitoneal space to preserve the left side for adjacent level exposure. Ureteral catheters are recommended to assist in identifying the ureters when ipsilateral retroperitoneal exposure is required.