Peripheral Arterial Trauma Research Articles

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Journal of Vascular Surgery Aims to be the premier international journal of medical, endovascular, and surgical care of vascular diseases. It aims to improve the management of patients with vascular disorders by publishing relevant papers focusing on investigation, management and prevention of aortic, cerebrovascular and peripheral arterial diseases, vascular access, trauma and malformations. The journal reports important medical advances, tests new hypotheses, and addresses current controversies.

Türkiye’de ampütasyonların endikasyonları, komplikasyonları ve revizyonları

Aim: The objective of this study is to determine the incidence of indications for amputations, major amputation related complications and revision numbers in Level I trauma center; which consists burn care unit, hyperbaric oxygen unit and hand surgery department in Turkey.
 Materials and Methods: Amputation procedures were retrospectively reviewed and evaluated according to the amputation levels, etiology, and demographic data. Major complications that require surgical intervention, type of surgical intervention for these complications and interval between index surgery and first complication related surgery were recorded. Re-amputations were evaluated according to interval between index and revision surgery, revision indication, and revised level.
 Results: A total of 558 amputations were performed for 476 patients (367 male, 109 female) in five-year period. The most common indication of amputation was diabetic complications, 250 amputations for 215 diabetic patients (44.8%) were performed. Peripheral arterial disease and trauma were the second and third common indications. The most common indication for upper extremity amputation was trauma. The most common amputation levels were hand amputations in the upper extremity, and below-knee amputation in the lower extremity. Fifty-seven of the surgical procedures were re-amputations and the interval between index surgery and revision amputation was 5.0±15.8 months. The most common indication for revision amputation was diabetic complications. Complications that required surgical intervention were infection in 46 patients, local soft tissue necrosis in 28 patients, and wound dehiscence in 2 patients.
 Conclusions: This is the first study investigating amputation etiology from high capacity hospital in capital city of Turkey that can demonstrate the whole country. The most common indications in this study were diabetic foot, PAD, and trauma as it is in developed countries. The results of this study can be the first step of multicenter epidemiological studies about amputations.

Current Therapeutic Strategies in Diabetic Foot Ulcers.

Diabetic foot ulcers (DFUs) are the fastest growing chronic complication of diabetes mellitus, with more than 400 million people diagnosed globally, and the condition is responsible for lower extremity amputation in 85% of people affected, leading to high-cost hospital care and increased mortality risk. Neuropathy and peripheral arterial disease trigger deformities or trauma, and aggravating factors such as infection and edema are the etiological factors for the development of DFUs. DFUs require identifying the etiology and assessing the co-morbidities to provide the correct therapeutic approach, essential to reducing lower-extremity amputation risk. This review focuses on the current treatment strategies for DFUs with a special emphasis on tissue engineering techniques and regenerative medicine that collectively target all components of chronic wound pathology.

Factores pronósticos para pérdida de extremidad con trauma arterial periférico en un hospital de Colombia

Introduction : Vascular trauma is a low frequency event, with high morbidity and mortality that affects the young population; In general, it requires surgical management. It is associated with complications from surgical reintervention to amputation of the limb, influenced by trauma associated variables such as hospital care. Aim : Determine risk factors related to amputation, in patients with peripheral arterial trauma (TAP), treated at a Hospital of III level Huila-Colombia between 2014-2017. Materials and Method: Observational, retrospective analytical study with patients older than 13 years with TAP. Results: We included 79 patients with an incidence of 1.56%. 89% men, average age 28.5 years. The main comorbidity was 8.8% drug dependence. The MESS (Mangled extremity severity) average was of 5.27 points and a critical time of limb ischemia > to 6 hours in 38%. The greater commitment was of superior members, secondary to injuries by sharp weapon. The predominant lesion was arterial transection. The main postoperative complications were vessel thrombosis (21.5%) and amputation in 13.9%. Risk factors associated with amputation were determined by age > 20 years, hospital stay > 7 days, MESS > 7 points, and that they presented arterial thrombosis as a surgical complication and finally required surgical reoperation. Conclusions: Peripheral arterial trauma is a pathology with great socioeconomic impact and functional sequelae. It is necessary the timely attention with treatment of the variables related to poor prognosis, in order to decrease the morbidity and mortality rates.

Operative management of non-iatrogenic pediatric and adolescence peripheral arterial trauma: An experience from a resource challenged setting

To evaluates the management and outcome of non-iatrogenic pediatric and adolescence extremity arterial injuries in a resource-challenged setting. A retrospective study of the surgical management for non-iatrogenic extremity arterial trauma in pediatric and adolescence during the period from January 2008 to December 2015. This study was performed in two different countries at tertiary referral university and teaching hospitals having a specialized emergency and trauma centers. A thorough study of each patient record was collected from these centers including, the original demographic data and their clinical presentations. Operative data of each patient was also reported. During the 8-year period of the study, 149 pediatric and adolescent extremity arterial trauma patients were treated. They were 93.3% male, and 6.7% female, respectively. The age ranged from 2 to 18 years with a mean of 10.25±4.05 years. Lower extremity arterial trauma was recorded in 51%, while 49% were having upper extremity injuries. Primary repair with end-to-end vascular anastomosis was performed in 51.7%, while an interposition reversed saphenous vein graft was performed in 48.3%. The operative procedures were performed by an experienced vascular surgeon and well-trained pediatric surgeons and general surgeons. Pseudoaneurysms was recorded in 9% of cases. Fasciotomy was performed in 15% of cases. Treatment of pediatric and adolescent extremity arterial injuries with primary end-to-end vascular anastomoses or with the use of an interposition reversed saphenous vein graft is a reliable, feasible, and more cost-effectiveness technique with good results. Moreover, it should be adopted for all vascular trauma patients, whenever possible.

Operative Management of Non-Iatrogenic Pediatric and Adolescent Peripheral Arterial Trauma: An Experience from a Resource-Challenged Setting

Operative Management of Non-Iatrogenic Pediatric and Adolescent Peripheral Arterial Trauma: An Experience from a Resource-Challenged Setting

Engineered Blood Vessels

The field of tissue engineering has has made significant progress in the past 20 years. Of the many tissues and organs in development, the area of vascular tissue engineering is now one of the most mature. In that regard, we have developed a novel tissue engineered vascular graft (human acellular vessel [HAV]) that addresses many of the limitations of native vein harvest and the performance of both synthetic ePTFE and autologous vein grafts. The HAV is manufactured in a laboratory by culturing human vascular cells within a biodegradable scaffold that forms a mechanically robust tissue engineered blood vessel. The cells are then completely removed (decellularization), leaving behind a non-immunogenic human collagen-based vascular tissue that can be stored on the shelf for months at a time and ready for immediate implantation into any patient. The HAV is currently being evaluated in Phase II and Phase III clinical trials in the U.S., E.U. and Israel as an arteriovenous vascular access graft for hemodialysis in patients with end-stage renal failure and as an arterial substitute for patients in need of vascular bypass for peripheral arterial disease or vascular trauma. Following clinical implantation, we have observed repopulation and remodeling of the manufactured vessel with the hosts' own cells. We hypothesize that the biological composition of the HAV, compared to synthetic vascular grafts, promotes its physiological integration into host tissue including support of normal host cell infiltration and function. Host cells that identify histologically similar to vascular smooth muscle cells appear to repopulate the middle of the vessel and recipient cells characterized as endothelial cells appear to cover the luminal surface of the implanted vessel. Clinical observations of the Phase II trials have demonstrated excellent vessel durability and a freedom from both early and delayed infection. Based on the success of the Phase II studies, a Global Phase III study is underway for patients in need of dialysis access shunts and vascular programs for vascular (arterial) bypass and trauma are expanding. DisclosuresLawson:InnaVasc: Patents & Royalties; Humacyte, Inc.: Employment.

Takotsubo Cardiomyopathy With a Rapidly Resolved Left Ventricular Thrombus.

This article presents the case of a 53-year-old man who presented with acute right superficial femoral and popliteal arterial thrombosis for which he underwent an emergent uncomplicated thrombectomy. He denied preceding cardiovascular or neurologic symptomatology and had no history of coronary or peripheral arterial disease, trauma, hypercoagulability, or malignancy. However, he reported having several days of intense emotional stress prior to presentation. His cardiac exam was normal, his electrocardiogram showed normal sinus rhythm and nonspecific ST-T wave abnormalities, and his troponin levels were normal. Transthoracic echocardiography (TTE) revealed a large (2.4 × 2 cm) apical left ventricle (LV) thrombus, LV apical akinesis, and LV ejection fraction of 40% to 45%. Coronary angiography revealed only luminal irregularities. A repeat TTE performed 3 days after initiating unfractionated heparin revealed complete resolution of the LV thrombus. The patient had an uneventful clinical course and was discharged home in stable condition on oral anticoagulants. The lower incidence of LV thrombus in takotsubo cardiomyopathy (TC) of 1.3% in comparison to 4% to 8% in acute myocardial infarction due to coronary artery disease in the current era of early reperfusion may be explained by the lower extent of ischemic myocardial necrosis associated with TC. This case suggests that the lower extent of myocardial necrosis in TC may also lead to faster resolution of LV thrombus. Therefore, earlier follow-up with TTE (within 2 weeks) and shorter duration of anticoagulation (<3 months) may be considered in patients with TC complicated by LV thrombus formation with or without systemic embolism.

Endovascular management for peripheral arterial trauma: The new norm?

BackgroundEndovascular therapy is well studied in atraumatic conditions; and there appears to be a growing interest in its application to traumatic injuries. The objective of this study is to compare open and endovascular techniques in the management of peripheral arterial trauma. MethodsThis is a retrospective review of patients admitted to a Level I Trauma Center sustaining injuries to the subclavian, axillary, superficial femoral, and popliteal arteries. Demographics, surgical interventions, complications, and clinical outcomes were evaluated in patients requiring open or endovascular repair between 2009 and 2015. ResultsSixty-eight patients with 70 total arterial injuries were identified. There were 10 subclavian, 14 axillary, 15 superficial femoral, and 31 popliteal artery injuries.Endovascular (n=20) compared to open repairs (n=50) were more commonly performed: by vascular surgeons (90% vs. 54%, p=0.01); in older patients (median age: 38 years vs. 25, p=0.01); primarily involving upper extremity injuries (60% vs. 24%, p=0.01). Furthermore, endovascular repairs less commonly required fasciotomy (15% vs. 46%, p=0.03) and trended towards lower transfusion requirements (50% vs. 77%, p=0.06). Patients undergoing open repair had lower pre-hospital systolic blood pressures (110 vs. 120, p=0.03) and lower initial hematocrit (31.5 vs. 36.2, p=0.02).However, outcomes between groups were trending higher in the endovascular group with respect to limb salvage rates at discharge (94% vs. 89%), median length of stay (14days vs. 9), and median follow-up (288days vs. 92) compared to the open group, but the data were not statistically significant. There was increasing utilization of endovascular repair over time (7% of total procedures in 2009; 50% in 2014). ConclusionsOverall, endovascular and open techniques were not statistically different in early outcomes. Endovascular therapy appears to provide some advantage when it comes to: challenging anatomy, decreasing blood product utilization, and minimizing physiologic derangement. However, patients with injuries resulting in free hemorrhage or significant external blood loss may still be best served with open repair. Despite this, given the increasing use of endovascular techniques, close collaboration is needed between trauma and endovascular specialists to properly select the optimal management for patients with peripheral arterial trauma.

Intraoperative indocyanine green angiography for the objective measurement of blood flow.

PurposeIntraoperative assessment of tissue perfusion is important to predict wound healing or improvement of symptoms in patients with peripheral arterial disease (PAD) or vascular trauma. There is no widely accepted standard for intraoperative measurement of tissue perfusion. Here, we report the use of indocyanine green (ICG)-based angiography to determine the blood flow in patients with PAD and vascular trauma.MethodsThe SPY fluorescent imaging system was utilized. A dose of 3–5 mL of ICG (2.5 mg/mL) was injected intravenously followed by a 10 mL normal saline flush. The SPY imaging system was used to quantitatively assess perfusion. During the study period, the SPY imaging system was applied in 4 patients with PAD and one patient with vascular trauma.ResultsIn 3 patients with PAD associated with an ischemic wound, complete wound healing was achieved with the indication of viable tissue by the SPY system. In one patient with severe claudication in both lower extremities, the ICG angiography was used to determine the increased blood flow after revascularization. In the case of vascular trauma, this imaging system enabled the delineation of viability of the injured tissue.ConclusionICG angiography can determine the surface tissue viability in PAD patients. In cases of severe vascular trauma,the SPY system can be used to determine tissue perfusion. Further study is warranted to define the definite utility of this technology to assess perfusion, response to revascularization, and potentially, to predict the likelihood of wound healing.

Outcomes after endovascular repair of arterial trauma

Endovascular repair of peripheral arterial trauma using covered stent grafts is a minimally invasive alternative to open surgery in selected patients. Although the technical feasibility of endovascular repair has been established, there are a paucity of data regarding outcomes. The purpose of this study was to evaluate the short-term outcomes of endovascular repair in patients with peripheral arterial trauma. A review of a prospectively collected institutional trauma registry captured all patients with peripheral arterial injury who underwent endovascular repair from August 2004 to June 2012. Data collected included demographics, Injury Severity Score (ISS), mechanism, location and type of injury, imaging modality, intervention type, complications and reintervention, length of stay, and follow-up. Descriptive statistics were used for analysis. During the study period, we performed endovascular repair in 28 patients with peripheral arterial injuries. There were 20 male patients (71%) with a median age of 39years (range, 13-88years). The mean ISS was 17.2 (range, 9-41). The mechanism of injury was penetrating in 21 (75%) and blunt in seven (25%). The anatomic locations of the 28 arterial injuries were carotid (3 [11%]), subclavian (7 [25%]), axillary (6 [22%]), iliac (3 [11%]), and femoral/popliteal (9 [32%]). Findings consistent with injury on imaging included pseudoaneurysms (9 [32%]), extravasations (9 [32%]), occlusions (6[22%]), and arteriovenous fistulas (4 [14%]). Technical success was achieved in all patients. The overall complication rate was 21%, with six patients requiring a secondary procedure. Two patients underwent a planned, elective conversion to open repair during the initial hospitalization. Four patients required conversion secondary to stent graft thrombosis. Three conversions were early (<30days) and one was late (>30days). The mean length of stay was 18.4± 22.9days (range, 1-93days), with a median follow-up of 13months (range, 1-60months). The overall limb salvage rate was 92% at 45days and 79% at 93days. The present study outlines our early experience with endovascular repair of peripheral arterial injuries in a variety of anatomic locations. Overall complication rates are appreciable but can be effectively detected and managed with additional intervention. The inclusion of endovascular modalities in algorithms of trauma care holds considerable promise. The need to better define optimal algorithms for utilization and determine long-term outcomes of intervention requires significant additional study.

What is the Potential for False Positive Results in Ankle Brachial Index Measurements Performed by Emergency Providers?

Introduction: The Ankle-Brachial Index measurement (ABI) is an easily performed bedside test used to screen for lower extremity arterial injury. It is possible that the ABI is not always correctly performed in the acute setting, depending on available equipment and provider familiarity with validated measurement techniques. We sought to determine the potential for false positive ABI results in healthy subjects if the ABI is performed incorrectly. We also sought to identify the method most likely to minimize false positive results. Materials and methods: Healthy volunteers and low acuity emergency department patients were enrolled. Exclusion criteria included a known history of documented peripheral arterial disease or extremity trauma. Subjects were examined by two investigators. “Most Accurate” (MA) ABI measurements used the higher of the two ankle readings and the higher of the two brachial readings to calculate the result. “Least Accurate” (LA) measurements used the lower of the two ankle readings and the higher of the two brachial readings. Results: 118 study subjects were enrolled: mean age 32.8 years (range 19 to 49), 50% female, none with known peripheral vascular disease or extremity trauma, and none with documented femoral artery bruit at the time of the study. When a single provider performed LA ABI’s, the false positive rate was 29%, while single provider MA ABI’s lowered the false positive rate to 2%. For two provider ABI’s, these rates were 4% and 0%, respectively. Conclusions: We identified an unacceptably high rate of false positive ABI results if the test is performed incorrectly. We recommend strict adherence to standardized ABI measurement protocols to minimize this error. Ideally, an ABI measurement of less than 0.9 in a patient with lower extremity trauma should be confirmed by a second provider in order to minimize the risk of inappropriately implementing invasive diagnostic procedures.

Use of Endovascular Therapy for Peripheral Arterial Lesions: An Analysis of the National Trauma Data Bank From 2007 to 2009

An endovascular approach is increasingly used for the treatment of peripheral arterial trauma (PAT), but evidence supporting this approach is lacking. The objective of our study was to assess outcomes for endovascular repair (ER) versus operative repair (OR) in PAT. We used the National Trauma Data Bank from 2007 to 2009 for our analysis, comparing in-hospital morbidity and mortality for all adult patients undergoing ER versus OR for PAT of the upper and lower extremities. Unadjusted and risk-adjusted generalized linear models were performed, with multiple imputation techniques being used to replace missing values. Of 8,977 patients, 531 (5.9%) underwent ER. Most patients were male (77.1%) and Caucasian (42.6%), with a mean age of 34.7 years (standard deviation: 14.8). ER was performed more commonly for lower- (n = 370, 10.4%) than upper-extremity lesions (n = 161, 3.0%, P < 0.001). Risk-adjusted analysis showed that ER patients had significantly greater injury severity scores (P < 0.001), were more likely to suffer a blunt (vs. penetrating) mechanism of injury (P < 0.001), and were more likely to have multiple comorbid illnesses (P < 0.001) than OR patients. Overall, risk-adjusted complications were less frequent after ER than OR (risk-adjusted OR: 0.79, P = 0.05), whereas in-hospital mortality between the two groups did not differ (risk-adjusted OR: 1.10, P = 0.59). Length of hospital stay was shorter among ER patients (adjusted mean difference: 0.78 days, P < 0.001), whereas length of intensive care unit stay did not differ between the two groups (P = 0.44). ER appears to be a viable option for patients with PAT. Further research is needed to identify potential subgroups of PAT patients in whom ER may be superior to OR.

Compartment syndrome and the role of fasciotomy in the reduction of ischemia in peripheral arterial trauma

Anesthesia & Intensive Care Unit, University Military Hospital-National Trauma Center, Tirana, Albania

Endovascular Treatment of Lower Limb Penetrating Arterial Traumas

The purpose of this study was to evaluate the effectiveness of percutaneous arterial embolization in patients with penetrating peripheral arterial trauma. Twelve patients with penetrating peripheral arterial trauma were treated with percutaneous arterial embolization between 2002 and 2007. All injuries were secondary to penetrating stab wounds. Active bleeding (eight patients), recurrent bleeding episodes (one patient), persistent pain and mass (one patient), leg edema, claudication, swelling (one patient), local hyperemia, and pain (one patient) were the presenting symptoms. Microcatheter systems were used for catheterization. We used n-butyl cyanoacrylate mixture as the embolizing agent in all patients. On angiograms the inferior gluteal artery (one patient), internal pudendal artery (one patient), perforating branch of the profundal femoral artery (six patients), superficial femoral artery (one patient), peroneal artery (two patients), and anterior tibial artery (one patient) were found to be injured. In all patients, the source of arterial bleeding could be reached, and a safe embolization was achieved. Nontarget embolization due to backflow of n-butyl cyanoacrylate mixture was detected in two patients and inguinal hematoma at the puncture site occurred in one patient. We conclude that embolization-particularly n-butyl cyanoacrylate embolization-is technically feasible in patients with penetrating peripheral arterial trauma.

Guidelines for the treatment of arterial insufficiency ulcers

1. Co-chaired panel 2. University of Utah, Salt Lake City, UT 3. University of Texas, San Antonio, TX 4. Sinai Hospital/Johns Hopkins Medical Institutions, Baltimore, MD 5. GKT School of Medicine, King’s College, London, UK 6. University of Texas Health Science Center at Houston, TX 7. Sequoia Hospital, Redwood City, CA 8. Maricopa Medical Center, Phoenix, AZ 9. Tufts-New England Medical Center, Boston, MA 10. Southampton University Hospitals Trust NHS, Southampton, UK 11. Penrose–St. Francis Health Services, Colorado Springs, CO 12. Beverly Surgical Associates, Beverly, MA 13. Saint Francis Memorial Hospital, San Francisco, CA 14. Northbay Center for Wound Care, Vacaville, CA, and 15. University of California, San Francisco, CA

Ultrasonic interrogation of tissue vibrations in arterial and organ injuries: Preliminary in vivo results

Soft tissues surrounding vascular injuries are known to vibrate at audible and palpable frequencies, producing bruits and thrills. We report the results of a feasibility study where Doppler ultrasound (US) was used to quantitatively estimate the tissue vibrations after induced trauma in an animal model. A software-programmable US system was used to acquire quadrature-demodulated ensembles of received US echoes bypassing clutter filtering and other conventional Doppler processing stages. The waveforms of tissue velocity surrounding the injury site were then estimated from the clutter data using autocorrelation and analyzed to determine vibration characteristics. Six New Zealand white rabbits and two juvenile pigs were used for the study. The femoral artery of the anesthetized animal was punctured with an 18-gauge needle to model a peripheral arterial trauma, and the liver was surgically exposed and incised to model organ trauma. Two types of oscillatory tissue motion were observed: “vibrations” with high frequency (>50 Hz) and low peak-peak amplitude (<1 μm) and “flutter” with low frequency (<50 Hz) and high peak-peak amplitude (>1 μm). Active bleeding in femoral artery punctures produced tissue vibrations at the frequency of 323 ± 214 Hz (mean ± standard deviation, pooled for both rabbits and pigs) and the amplitude of 0.24 ± 0.15 μm. Active bleeding in liver incisions produced vibrations at the frequency of 120 ± 47 Hz and the amplitude of 0.33 ± 0.25 μm. Flutter was observed in punctured arteries at the frequency of 28 ± 13 Hz the amplitude of 2.92 ± 1.75 μm, and in incised livers at the frequency of 26 ± 6 Hz and the amplitude of 1.53 ± 0.76 μm. In a punctured artery, the vibration frequency and phase of tissue surrounding the artery were highly correlated between neighboring locations in tissue (correlation coefficient = 0.98), and with the flow oscillations in the lumen (correlation coefficient = 0.96). This preliminary study indicates that tissue vibrations could provide additional physiologic information for detecting, localizing and monitoring internal bleeding using US. (E-mail: ssikdar@u.washington.edu)

Civil and War Peripheral Arterial Trauma: Review of Risk Factors Associated with Limb Loss

We sought to analyze the early results of civil and war peripheral arterial injury treatment and to identify risk factors associated with limb loss. Between 1992 and 2001, data collected retrospectively and prospectively on 413 patients with 448 peripheral arterial injuries were analyzed. Of these, there were 140 patients with war injuries and 273 patients with civil injuries. The mechanism of injury was gunshot in 40%, blunt injury in 24%, explosive trauma in 20.3%, and stabbing in 15.7% of the cases. The most frequently injured vessels were the femoral arteries (37.3%), followed by the popliteal (27.8%), axillary and brachial (23.5%), and crural arteries (6.5%). Associated injuries, which included bone, nerve, and remote injuries affecting the head, chest, or abdomen, were present in 60.8% of the cases. Surgery was carried out on all patients, with a limb salvage rate of 89.1% and a survival rate of 97.3%. In spite of a rising trend in peripheral arterial injuries, our total and delayed amputation rates remained stable. On statistical analysis, significant risk factors for amputation were found to be failed revascularization, associated injuries, secondary operation, explosive injury, war injury (p < .01) and arterial contusion with consecutive thrombosis, popliteal artery injury, and late surgery (p < .05). Peripheral arterial injuries, if inadequately treated, carry a high amputation rate. Explosive injuries are the most likely to lead to amputations, whereas stab injuries are the least likely to do so. The most significant independent risk factor for limb loss was failed revascularization.

Civil and War Peripheral Arterial Trauma: Review of Risk Factors Associated with Limb Loss

Civil and War Peripheral Arterial Trauma: Review of Risk Factors Associated with Limb Loss

Foreign body arterial embolus to the hand

I ntravascular foreign body emboli to the upper extremity, although distinctly uncommon, can result from penetrating central or peripheral arterial trauma. L-3 These have previously been reported in the axillary and brachial arteries4‘9 but not in the arteries of the forearm or hand. A novel case of metal embolus from the radial artery in the forearm to the deep palmar arch in the hand is described. Plain x-ray films and physical examination supported the diagnosis. Physical examination, Doppler evaluation, and occasionally angiography can reliably define the urgency of surgical intervention.