Intraoperative Arterial Injury Research Articles

Arterial Resection for Pancreatic Cancer: Feasibility and Current Standing in a High-Volume Center.

Arterial resection (AR) during pancreatectomy for curative R0 resection of pancreatic ductal adenocarcinoma (PDAC) remains a controversial procedure with high morbidity. To investigate the feasibility and oncological outcomes of pancreatectomy combined with AR at a high-volume center for pancreatic surgery. We retrospectively analyzed our experience in PDAC patients, who underwent pancreatic resection with AR and/or venous resection (VR) between 2007 and 2021. In total 259 PDAC patients with borderline resectable (n = 138) or locally advanced (n = 121) PDAC underwent vascular resection during tumor resection. From these, 23 patients had AR (n = 4 due to intraoperative injury, n = 19 due to suspected arterial infiltration). However, 12 out of 23 patients (52.2%) underwent simultaneous VR including 1 case with intraoperative arterial injury. In comparison, 11 patients (47.8%) underwent AR only including 3 intraoperative arterial injury patients. Although the operation time and bleeding rate of patients with AR were respectively longer and higher than in VR, no significant difference was detected in postoperative complications between VR and AR (P = 0.11). The final histopathological findings of PDAC patients were similar, including M stage, regional lymph node metastases, and R0 margin resection. The mortality of the entire cohort was 6.2% (16/259), with a tendency to increase mortality in the AR cohort, yet without statistical significance (VR: 5% vs AR: 21.1%; P = 0.05). Although 19 (82.6%) patients had PDAC in the final histopathology, only 6 were confirmed to have infiltrated arteria. The microscopic distribution of PDAC in these infiltrated arterial walls on hematoxylin-eosin staining was classified into 3 patterns. Strikingly, the perivascular nerves frequently exhibited perineural invasion. AR can be performed in high-volume centers for pancreatic surgery with an acceptable morbidity, which is comparable to that of VR. However, the likelihood of arterial infiltration seems to be rather overestimated, and as such, AR might be avoidable or replaced by less invasive techniques such as divestment during PDAC surgery.

Pembrolizumab and ramucirumab neoadjuvant therapy for PD-L1-positive stage IB-IIIA lung cancer (EAST ENERGY).

8509 Background: Neoadjuvant treatments for resectable non-small cell lung cancer (NSCLC) using novel combination therapies are being developed. Angiogenesis inhibitors have been reported to modify tumor immunity, and the efficacy and safety of treatments added to immune checkpoint inhibitors (ICIs) have been investigated in advanced NSCLC. In this multi-institutional phase II study, we evaluated the efficacy and feasibility of neoadjuvant therapy with pembrolizumab and ramucirumab, a direct vascular endothelial growth factor (VEGF) receptor-2 antagonist, followed by surgery, in patients with PD-L1 positive, clinical stage IB-IIIA NSCLC. Methods: Patients (aged ≥20) with pathologically proven NSCLC harboring PD-L1 expression ≥1% (22C3), resectable clinical stage IB-IIIA NSCLC, and performance status of 0 to 1 were eligible. Patients received two cycles of pembrolizumab (200 mg/body) and ramucirumab (10 mg/kg) every three weeks. Surgery was scheduled 4-8 weeks after the last dose. The primary endpoint was to determine the major pathologic response (MPR) rate. The sample size was calculated based on the exact binomial distribution, considering a threshold MPR rate of 20%, an expected MPR rate of 45%, a one-side alpha of 5%, and a desired power of 80%. Results: A total of 24 eligible patients, with a median age of 75 years (range 50-78), were enrolled between July 2019 and April 2022; 18 patients were male. The histological subtype was adenocarcinoma in 12 patients, and the clinical stage was IB, IIA, IIB, and IIIA in 1, 4, 9, and 10 patients, respectively. PD-L1 was ≥50% in nine patients (37.5%). The MPR rate by the blinded independent central review of three pathologists was 50.0% (90% confidence interval, 31.9-68.1%); therefore, the primary endpoint was met. Six of the 12 patients who achieved MPR showed pathological complete response. One patient developed pneumonia before neoadjuvant treatment and one patient showed progressed disease after neoadjuvant treatment. Grade 3 adverse events (AEs) occurred in nine of 24 patients (37.5%) during the protocol treatment. Postoperative complications of grade 3 AEs, including postoperative hematoma, pulmonary fistula, and intraoperative arterial injury, were observed in three patients. Immune-related AEs related to protocol treatment were thyroid dysfunction, acute tubulointerstitial nephritis, and hepatic dysfunction in three, two, and two patients, respectively; however, no grade 3 or high AEs were observed. Twenty-one patients achieved R0 resection and one patient underwent R1 resection. There were no wound-healing adverse events of concern due to the anti-VEGF action of ramucirumab. Conclusions: The results of this study demonstrated that this new neoadjuvant combination of ICI and anti-VEGF agent (pembrolizumab and ramucirumab) is feasible and showed encouraging results. Clinical trial information: NCT04040361 .

Pancreatoduodenectomy in a patient with celiac axis stenosis and a replaced common hepatic artery: A case report.

IntroductionEvaluation of anatomical variations is important in pancreatoduodenectomy (PD) because an arterial anomaly is a risk factor for morbidity. Herein, we report a rare case of PD for lower bile duct cancer in which celiac axis stenosis and a replaced common hepatic artery (rCHA) coexisted.Presentation of caseAn 84-year-old woman presented with epigastric pain. She was diagnosed with a lower bile duct cancer and underwent PD. Preoperative computed tomography showed celiac axis stenosis, and the deformed celiac artery had a “hooked appearance,” suggesting compression by the median arcuate ligament (MAL). The rCHA branched from the superior mesenteric artery. The gastroduodenal artery (GDA) diverged from the rCHA, forming a developed arterial arcade of the pancreatic head. There was an oncological safety margin between the rCHA and common bile duct; however, a part of the collateral artery was close to the common bile duct. Therefore, we planned to preserve the rCHA and resect the GDA to form collateral circulation. The MAL was divided and we evaluated the blood flow of the left upper abdominal organs using indocyanine green fluorescence imaging with a near-infrared camera system. We considered that perfusion of organs was preserved, and PD was performed without vessel reconstruction. No ischemic complication occurred in the postoperative course.DiscussionThe coexistence of these arterial anomalies made the procedure of PD more complicated.ConclusionPrecise preoperative diagnosis of arterial anomalies is necessary to avoid postoperative complications that may be induced by intraoperative arterial injury and organ ischemia.

795 Trends in Cerebrospinal Fluid Leak Rates Following the Extended Endoscopic Endonasal Approach for Anterior Skull Base Meningioma: A Meta-Analysis Over the Last 20 Years

Abstract Introduction The extended endoscopic approach (EEA) provides direct access for resection of tuberculum sellae (TSM) and olfactory groove meningiomas (OGM) but is associated with cerebrospinal fluid (CSF) leak in up to 25% of patients. To evaluate the impact of improved skull base reconstructive techniques, we assessed published CSF leak percentages in EEA over the last two decades. Method Random-effects meta-analyses were performed for studies published between 2004-2020. Outcomes assessed were CSF leak, gross total resection, visual improvement, intraoperative arterial injury and 30-day mortality. For the main analyses, publications were pragmatically grouped based on publication year in three categories: 2004-2010, 2011-2015, and 2016-2020. Results We included 29 studies describing 540 TSM and 115 OGM patients. CSF leak incidence dropped over time from 22% (95% CI: 6-43%) in studies published between 2004 and 2010, to 16% (95% CI: 11-23%) between 2011 and 2015, and 4% (95% CI: 1-9%) between 2016 and 2020. Outcomes of gross total resection, visual improvement, intraoperative arterial injury, and 30-day mortality remained stable over time Conclusions We report a noticeable decrease in CSF leak over time, which might be attributed to the development of reconstructive techniques (e.g., hadad bassagasteguy flap, and gasket seal), refined multilayer repair protocols, and selected lumbar drain usage.

Rib-sparing scalenectomy for neurogenic thoracic outlet syndrome: Early results

ObjectiveNeurogenic thoracic outlet syndrome (NTOS) is no longer either “controversial” or “disputed”; however, its optimal surgical management remains unclear. Many thoracic outlet decompression procedures are performed by first rib resection, usually via a transaxillary route. MethodsA retrospective review of a prospectively maintained NTOS database was performed. Patients with NTOS associated with a cervical rib and those with recurrent NTOS were excluded from the present analysis. All study patients had satisfied a 5-point clinical diagnostic protocol and had experienced a positive response to a local anesthetic scalene block. Surgical decompression included anterior, minimus, and middle scalenectomy and brachial plexus neurolysis via a supraclavicular incision and pectoralis minor tenotomy through a small vertical infraclavicular incision. No first ribs were excised. All the patients had completed QuickDASH (11-item version of the Disability of the Arm, Shoulder, and Hand questionnaire) preoperatively and at 3 or 6 months postoperatively. ResultsFrom 2011 to 2019, 504 thoracic outlet decompression procedures had been performed in 442 patients. The average operative time was 1.15 hours, and the average hospital length of stay was 1.05 days. Major complications, including intraoperative arterial injury, postoperative wound hematoma requiring reoperation, and chylothorax, occurred in 7 patients (1.4%). All but 2 patients (99.6%) had symptomatic improvement. Using a more rigorous definition of operative success of ≥50% improvement in the 3- or 6-month QuickDASH score, 458 rib-sparing NTOS operations (90.9%) were successful. In contrast to the mean preoperative QuickDASH score of 62.6, the average postoperative QuickDASH score was 25.2 (P = .001). ConclusionsThese results suggest that (1) adherence to a rigorous preoperative diagnostic regimen, including performance of a scalene block, ensures, at the least, that surgery for NTOS can be successfully restricted to patients actually with the condition; (2) fibrotic, contracted scalene muscles are the cause of NTOS; (3) the first rib does not require removal for successful surgical treatment of NTOS; and (4) 90% of the patients so treated can expect significant early symptomatic and functional improvement.

Primary total hip replacement using Burch-Schneider cages for acetabular fractures.

Osteoporotic acetabular fractures are common and pose a difficult technical challenge for the trauma surgeon. Acute total hip arthroplasty (THA) using a Burch-Schneider antiprotrusio cage with immediate postoperative weight-bearing is a method to approach these injuries. This case series reports our outcomes of acute THA using Burch-Schneider cages for acetabular fractures from a UK major trauma centre based on length of stay, radiological outcome, complications and outcome scores. Data were collected from all patients who underwent acute THA with a Burch-Schneider cage for acetabular fractures between June 2006 and August 2015. Patients were followed up clinically, radiologically, and using Oxford Hip Scores (OHS). 20 patients with a median age of 73 (range 60-90 years) were identified. All patients were independent walkers at follow-up, and had achieved radiological union. There were no dislocations, subsidence, revision or deep infections. Significant complications include 1 perioperative death as a result of complications arising from pre-existing pulmonary fibrosis; 1 deep vein thrombosis; 1 intraoperative arterial injury to the superior gluteal artery; and 1 leg-length discrepancy. Mean length of stay was 10 days. The mean OHS was 37/48 at a mean follow-up of 26 months. This case series further validates the use of Burch-Schneider cages with primary THA in acute acetabular fractures.

The endoscope-assisted supraorbital \u201ckeyhole\u201d approach for anterior skull base meningiomas: an updated meta-analysis

IntroductionThe gold-standard treatment for symptomatic anterior skull base meningiomas is surgical resection. The endoscope-assisted supraorbital “keyhole” approach (eSKA) is a promising technique for surgical resection of olfactory groove (OGM) and tuberculum sellae meningioma (TSM) but has yet to be compared with the microscopic transcranial (mTCA) and the expanded endoscopic endonasal approach (EEA) in the context of existing literature.MethodsAn updated study-level meta-analysis on surgical outcomes and complications of OGM and TSM operated with the eSKA, mTCA, and EEA was conducted using random-effect models.ResultsA total of 2285 articles were screened, yielding 96 studies (2191 TSM and 1510 OGM patients). In terms of effectiveness, gross total resection incidence was highest in mTCA (89.6% TSM, 91.1% OGM), followed by eSKA (85.2% TSM, 84.9% OGM) and EEA (83.9% TSM, 82.8% OGM). Additionally, the EEA group had the highest incidence of visual improvement (81.9% TSM, 54.6% OGM), followed by eSKA (65.9% TSM, 52.9% OGM) and mTCA (63.9% TSM, 45.7% OGM). However, in terms of safety, the EEA possessed the highest cerebrospinal fluid leak incidence (9.2% TSM, 14.5% OGM), compared with eSKA (2.1% TSM, 1.6% OGM) and mTCA (1.6% TSM, 6.5% OGM). Finally, mortality and intraoperative arterial injury were 1% or lower across all subgroups.ConclusionsIn the context of diverse study populations, the eSKA appeared not to be associated with increased adverse outcomes when compared with mTCA and EEA and offered comparable effectiveness. Case-selection is paramount in establishing a role for the eSKA in anterior skull base tumours.

Thirty-year experience of transaxillary resection of first rib for thoracic outlet syndrome.

Thoracic outlet syndrome is an important clinical entity, which usually affects young patients and working cohort, causing disability if unrecognized and untreated. Although treatment is commonly conservative, in patients with more severe disease, surgical treatment is often required for decompression. Purpose of this paper was to evaluate the surgical and clinical outcomes of patients who underwent first rib resection through transaxillary approach for thoracic outlet syndrome (TOS) during a period of 30 years. A retrospective study was conducted on a prospectively compiled, computerized database between January 1988 and December 2018 including patients affected by TOS surgically treated in two Italian centers, by the same surgeon. Patients with neurogenic and vascular TOS were included in the present analysis. The surgical approach for TOS decompression was the first rib resection using the Roos' transaxillary approach, with small variations in technique. Outcome measures considered for analysis were primary technical success, 30-day and mean follow-up re-intervention, pneumothorax, nerve injury and symptoms recurrence rates. One hundred three patients were treated: 89 (86.4%) women and 14 (13.6%) man; median age was 32.6±10.2 years (range 9-53). Prominent symptoms were neurogenic in 60 patients (58.2%), venous in 32 (31.1%), and arterial in 11 (7.76%) patients. In 49 patients (47.5%) with prominent neurogenic symptoms, concomitant symptoms of vascular TOS were also presents. Thirteen (12.6%) patients had cervical rib and sixteen cases (15.5%) had bilateral TOS. Technical success was achieved in all cases, and no other surgical access or secondary approach was necessary. Three patients (2.9%) presented with hand ischemia and also needed an arm vein bypass after rib resection. One (0.9%) intraoperative arterial injury was reported and nerve injury rate was 1.8%. At 30-day re-intervention rate was 0.9%: one patient experienced hemothorax solved by thoracoscopic drainage. Restrict pneumothorax was reported in 42 patients (40.8%) treated through pleural drainage. At mean follow-up of (93±9 months) partial symptoms recurrence was present in 6 patients (5.8%). In our experience first rib resection through the transaxillary approach is a safe and feasible procedure associated with an acceptable rate of peri-operative morbidity and satisfactory long-term relief of symptoms.

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.

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

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

The endoscopic endonasal approach is not superior to the microscopic transcranial approach for anterior skull base meningiomas\u2014a meta-analysis

ObjectIn the past decade, the endonasal transsphenoidal approach (eTSA) has become an alternative to the microsurgical transcranial approach (mTCA) for tuberculum sellae meningiomas (TSMs) and olfactory groove meningiomas (OGMs). The aim of this meta-analysis was to evaluate which approach offered the best surgical outcomes.MethodsA systematic review of the literature from 2004 and meta-analysis were conducted in accordance with the PRISMA guidelines. Pooled incidence was calculated for gross total resection (GTR), visual improvement, cerebrospinal fluid (CSF) leak, intraoperative arterial injury, and mortality, comparing eTSA and mTCA, with p-interaction values.ResultsOf 1684 studies, 64 case series were included in the meta-analysis. Using the fixed-effects model, the GTR rate was significantly higher among mTCA patients for OGM (eTSA: 70.9% vs. mTCA: 88.5%, p-interaction < 0.01), but not significantly higher for TSM (eTSA: 83.0% vs. mTCA: 85.8%, p-interaction = 0.34). Despite considerable heterogeneity, visual improvement was higher for eTSA than mTCA for TSM (p-interaction < 0.01), but not for OGM (p-interaction = 0.33). CSF leak was significantly higher among eTSA patients for both OGM (eTSA: 25.1% vs. mTCA: 10.5%, p-interaction < 0.01) and TSM (eTSA: 19.3%, vs. mTCA: 5.81%, p-interaction < 0.01). Intraoperative arterial injury was higher among eTSA (4.89%) than mTCA patients (1.86%) for TSM (p-interaction = 0.03), but not for OGM resection (p-interaction = 0.10). Mortality was not significantly different between eTSA and mTCA patients for both TSM (p-interaction = 0.14) and OGM resection (p-interaction = 0.88). Random-effect models yielded similar results.ConclusionIn this meta-analysis, eTSA was not shown to be superior to mTCA for resection of both OGMs and TSMs.

Managing Arterial Injury in Endoscopic Skull Base Surgery: Case Series and Review of the Literature

The most feared complications following endoscopic endonasal skull base surgery are arterial vascular injuries. Previously published literature is restricted to internal carotid artery injuries. The ideal method for controlling arterial bleeding during this kind of procedure is debated, and a variety of techniques have been advocated. To evaluate the management and outcome following intraoperative arterial injury during endoscopic endonasal skull base surgery. We performed a retrospective review of a prospectively acquired database of consecutive endonasal endoscopic surgeries at the New York-Presbyterian Hospital/Weill Cornell Medical Center from December 2003 to June 2015 and identified all cases of arterial injury. Of 800 cases, there were 4 arterial injuries (0.5%), of which only one involved the internal carotid artery (ICA), for a risk of 0.125%. The other 3 involved the ophthalmic artery, anterior communicating artery, and A1 segment of the anterior cerebral artery. In all cases, definitive treatment involved occlusion of the artery either through endovascular means (3 cases) or direct surgical ligation (1 case). Neurological examinations were unchanged after arterial repair with only 1 small asymptomatic stroke. Literature review identified 7336 patients, of which there were 25 arterial injuries, of which 19 were of the ICA. Hence, the total rate of arterial injury was 0.34% and the rate of ICA injury was 0.26%. Arterial sacrifice was the only reliable method for managing arterial injury. Arterial injury is an uncommon event after endoscopic endonasal surgery. Attempts at arterial repair are rarely successful, and vessel sacrifice is the most reliable technique at this point.

Predictive Factors of Neurovascular and Tendon Injuries Following Dog Bites to the Upper Extremity.

Background: Dog bite injuries to the upper extremity can result in traumatic neurovascular and musculotendinous damage. Currently, there are no clear guidelines dictating which patients may benefit from early operative exploration. The purpose of this study was to identify clinical variables that were predictive of abnormal intraoperative findings in patients who sustained an upper extremity dog bite injury. Methods: All patients who presented to a level I trauma center between 2007 and 2015 with an upper extremity dog bite injury who underwent subsequent surgical exploration were retrospectively screened for inclusion in our study. Patients with inadequate documentation or preexisting neurovascular or motor deficits were excluded. Abnormalities on physical exam and injuries encountered during surgical exploration were recorded for each patient. Contingency tables were constructed comparing normal and abnormal nerve, tendon, and vascular physical exam findings with intact or disrupted neurovascular and musculotendinous structures identified during surgical exploration. Results: Between 2007 and 2014, 117 patients sustained a dog bite injury to the upper extremity, of which 39 underwent subsequent surgical exploration and were included in our analysis. Sixty-nine percent of patients with neuropraxia on exam had intraoperative nerve damage. Seventy-seven percent of patients with an abnormal tendon exam had intraoperative musculotendinous damage. One hundred percent of patients with an abnormal vascular physical exam had intraoperative arterial injury. Conclusions: To date, there are no clear guidelines on what clinical criteria indicate the need for operative exploration and possible repair of neurovascular structures in upper extremity dog bite injuries. In our study, nerve, tendon, and vascular abnormalities noted on physical exam were strongly predictive of discovering neurovascular and musculotendinous damage during surgical exploration.

Managing Arterial Injury in Endoscopic Skull Base Surgery. Case Series and Review of the Literature

Background The most feared complications following endoscopic endonasal skull base surgery are arterial vascular injuries. Previously published literature is restricted to internal carotid artery injuries. The ideal method for controlling arterial bleeding during this kind of procedure is debated, and a variety of techniques have been advocated. Objective To evaluate the management and outcome following intraoperative arterial injury during endoscopic endonasal skull base surgery. Methods We performed a retrospective review of a prospectively acquired database of consecutive endonasal endoscopic surgeries at the New York-Presbyterian Hospital/Weill Cornell Medical Center from December 2003 to June 2015 and identified all cases of arterial injury. Results Of 800 cases, there were 4 arterial injuries (0.5%), of which only one involved the internal carotid artery (ICA), for a risk of 0.125%. The other 3 involved the ophthalmic artery, anterior communicating artery, and A1 segment of the anterior cerebral artery. In all cases, definitive treatment involved occlusion of the artery either through endovascular means (3 cases) or direct surgical ligation (1 case). Neurological examinations were unchanged after arterial repair with only 1 small asymptomatic stroke. Literature review identified 7336 patients, of which there were 25 arterial injuries, of which 19 were of the ICA. Hence, the total rate of arterial injury was 0.34% and the rate of ICA injury was 0.26%. Arterial sacrifice was the only reliable method for managing arterial injury. Conclusion Arterial injury is an uncommon event after endoscopic endonasal surgery. Attempts at arterial repair are rarely successful, and vessel sacrifice is the most reliable technique at this point.

Popliteal Pseudoaneurysm After Total Knee Arthroplasty Secondary to Intraoperative Arterial Injury With a Surgical Pin: Review of the Literature

Pseudoaneurysms of the popliteal artery after total knee arthroplasty are rare. Although many possible explanations are proposed in the literature, no intimate mechanism of injury to the artery is previously described. We report on a case of popliteal pseudoaneurysm after a total knee arthroplasty that presented clinically on the second postoperative day. Open vascular surgery with resection of the pseudoaneurysm and end-to-end bypass of contralateral saphena vein graft was successfully performed. At the time of the surgery, a hole was clearly identified on the anterior wall of the popliteal artery due to a perforation with a pin used during the knee arthroplasty. The patient had no further complications.

External iliac artery thrombosis associated with the ilio-inguinal approach in the management of acetabular fractures: a case report

IntroductionThe ilio-inguinal approach has come to be used routinely in the management of acetabular fractures involving the anterior wall. Thrombotic complications following surgery via this route are a serious, but rare, complication.Case presentationWe report the case of a 66-year-old male patient who slipped on an icy pavement and fell on his left hip. He sustained a comminuted acetabular fracture (a transtectal T-fracture with an incomplete posterior stem through the ischial tuberosity), and was operated on five days later, via an ilio-inguinal approach. In the recovery room, his left lower limb was found to be cool and pale. Immediate re-exploration showed a left external iliac artery thrombosis, and thrombectomy was performed. In the surgical management of acetabular fractures, thrombosis of a major pelvic artery is a rare but potentially devastating complication. We discuss the possible aetiology (initial vessel trauma versus iatrogenic, intraoperative arterial injury) and pathomechanism, and wish to draw attention to this complication and to recommend ways in which it can be prevented.ConclusionWe recommend circulation monitoring in patients with acetabular fractures, especially where nerve blocks and/or deep sedation/analgesia have been used. High-risk patients should be identified and subjected to intensive preoperative screening, including ultrasonography and if necessary angiography.

External Iliac Artery Thrombosis After Open Reduction of an Acetabular Fracture: A Case Report

Major arterial injury from open reduction and internal fixation of an acetabular fracture through an ilioinguinal approach is rare. Detection of a major intraoperative arterial injury is simple. Detection of a more occult injury leading to thrombosis is not. We report the third known case of thrombosis of the external iliac artery following open reduction and internal fixation of an anterior column fracture. This case is of particular interest because it highlights the ability of young patients to compensate for major vessel occlusion and still maintain a well-perfused foot. Heightened awareness of subtle side-to-side differences in pulses postoperatively may reveal that occult injury is a more common occurrence than previously appreciated.

Chordomas and chondrosarcomas of the skull base: results and complications of surgical management

Chordomas and chondrosarcomas are rare and difficult to treat tumors for which the optimum treatment modality remains controversial. The aim of this study was to evaluate the surgery-related results and complications in a series of patients in whom radical resection was the treatment of choice. The authors conducted a retrospective analysis of the surgery-related results and complications associated with chordoma and chondrosarcoma in 64 patients of whom 33 (52%) had previously undergone some form of treatment. Total or near-total excision was achieved in 56% and this rate increased to 68% in patients without prior treatment. The main complications were postoperative cerebrospinal fluid leakage, intraoperative arterial injury, and new-onset cranial nerve deficits. Arterial injury occurred only and perioperative death occurred more often in patients who had undergone previous treatment. Analysis of the results provides support for a policy of radical excision of chordomas and chondrosarcomas at the time of first presentation. A higher incidence of procedure-related complications is found in patients who have already undergone surgery and radiotherapy.

Percutaneous Treatment of an Intraoperative Arterial Injury as a Result of Endoureterotomy

A 35-year-old woman presented with a left ureteroileal anastomotic stricture 6 months in duration. She had undergone 2 previous balloon dilations of the stricture without success and an internallexternal stent had been placed. At presentation to our institution the patient was obese with mild diffuse abdominal tenderness. The stoma appeared viable with a ureteral stent extending into the stoma bag. Standard laboratory investigations were within the normal range. The patient refused open surgical repair but agreed to less invasive endourological stricture management. With the patient under general anesthesia and with fluoroscopic guidance a guide wire was passed through the existing left ureteral stent and coiled in the left renal pelvis, and the stent was removed. A pull-back retrograde study of the left ureter showed a 2 cm. stricture at the left ureteroiled anastomosis. Attempted dilation of the stricture via the traditional balloon technique failed and endourological treatment with a cutting balloon was performed. The Acucise* cutting balloon was passed over the guide wire and positioned at the stricture site under fluoroscopic guidance with the cutting wire directed anteriorly. The balloon was gently inflated until a waist was noted and the cutting current was applied to open the stricture. However, blood issued from the ileal conduit. The balloon was removed and found to be rup tured. An 8 mm. x 4 cm. angioplasty balloon was passed over the guide wire and inflated across the same site with prompt cessation of bleeding. Endoscopy showed an intact ileal loop and the angioplasty balloon was inflated at the uretemnteric anastomotic site. Partial deflation of the balloon under direct vision caused renewed bleeding. Although the condition of the patient was stable, there was concern regarding the source of bleeding. A pelvic arteriogram through a right femoral artery puncture revealed a small pseudoaneurysm with extravasation in the region of the distal left common iliac artery close to the distal left ureter. A 25 cm. long, 9F introducer sheath was passed through the left common femoral artery and positioned at the injury site. A thin walled 3 mm. X 3 cm. polytetrafluomthylene (Gore-Text) graft with the outer layer removed was fixed to a P-294 Palmaz stent$ with &zero polypropylene suture (fig. 1). The catheter was mounted on an 8 mm. x 4 cm. balloon and advanced through the introducer sheath into the left common iliac artery. The stent was deployed at the site of injury, and the balloon was deflated and removed. Completion angiography showed the stent to be in good psition with no leak and exclusion of the pseudoaneurysm.

Percutaneous Treatment of an Intraoperative Arterial Injury as a Result of Endoureterotomy

Percutaneous Treatment of an Intraoperative Arterial Injury as a Result of Endoureterotomy