Vascular Surgery Unit Research Articles

Carbapenem-Resistant KPC- and TEM-Producing Escherichia coli ST131 Isolated from a Hospitalized Patient with Urinary Tract Infection: First Isolation in Molise Region, Central Italy, July 2018

In July 2018, a Klebsiella pneumoniae carbapenemase (KPC)-producing Escherichia coli ST131 was isolated from a patient admitted to the Vascular Surgery Unit of the main hospital of Molise region, Central Italy. Sequencing and alignment with the available sequences revealed that the isolate harbored the KPC-2 variant and TEM-1 beta-lactamase. This observation raises great concerns about the spread of carbapenem resistance in national and local settings with high endemicity level of KPC in K. pneumoniae, and underlines the importance of strengthening a proactive surveillance.

Factores de riesgo cardiovascular en pacientes intervenidos de estenosis carotídea en el Hospital 12 de Octubre

Objetivos. Analizar los factores de riesgo asociados a la estenosis carotídea en los enfermos operados por esta patología desde enero de 2013 hasta diciembre de 2017 en el Servicio de Cirugía Vascular del Hospital Universitario 12 de Octubre de Madrid.Material y método. Estudio descriptivo, retrospectivo observacional, en el que se analizan las historias clínicas de los pacientes intervenidos de estenosis carotídea para identificar los factores de riesgo asociados a esta patología.Resultados. 161 pacientes fueron intervenidos, con una media de edad de 72 años ± 9,68. Un 80% fueron hombres (n=129) y un 20% mujeres (n=32). El 44.7% de los casos tenía entre 70 y 80 años. En este rango se sitúa también el mayor porcentaje de enfermos sintomáticos, correspondiendo estos a un 55.3% (n=89) del total de la muestra. La hipertensión y la dislipemia fueron los factores más prevalentes. La sintomatología previa y la hipertensión guardan una relación significativa (p≤0,05), así como el ser fumador o exfumador y ser hombre.Discusión-conclusión. Los factores de riesgo identificados en la bibliografía fueron encontrados en la muestra de estudio. Todos presentaban algún factor de riesgo. El control de dichos factores es un aspecto importante del tratamiento médico.

An evaluation of the validity of nutrition screening and assessment tools in patients admitted to a vascular surgery unit.

Vascular surgery patients are nutritionally vulnerable. Various malnutrition screening and assessment tools are available; however, none has been developed or validated in vascular patients. The present study aimed to: (1) investigate the validity of four commonly administered malnutrition screening tools (Malnutrition Screening Tool (MST), Malnutrition Universal Screening Tool (MUST), Nutrition Risk Screen-2002 (NRS-2002) and the Mini-Nutritional Assessment - Short Form (MNA-SF) and an assessment tool (the Patient-Generated Subjective Global Assessment (PG-SGA)) compared against a comprehensive dietitian's assessment and (2) evaluate the ability of the instruments to predict outcomes. Vascular inpatients were screened using the four malnutrition screening tools and assessed using the PG-SGA. Each was assessed by a dietitian incorporating nutritional biochemistry, anthropometry and changes in dietary intake. Diagnostic accuracy, consistency and predictive ability were determined. A total of 322 (69·3 % male) patients participated, with 75 % having at least one parameter indicating nutritional deficits. No instrument achieved the a priori levels for sensitivity (14·9-52·5 %). Neither tool predicted EuroQoL 5-dimension 5-level score. All tools except the MNA-SF were associated with length of stay (LOS); however, the direction varied with increased risk of malnutrition on the MUST and NRS-2002 being associated with shorter LOS (P=0·029 and 0·045) and the reverse with the MST and PG-SGA (P=0·005 and <0·001). The NRS-2002 was associated with increased risk of complications (P=0·039). The MST, NRS-2002 and PG-SGA were predictive of discharge to an institution (P=0·004, 0·005 and 0·003). The tools studied were unable to identify the high prevalence of undernutrition; hence, vascular disease-specific screening and/or assessment tools are warranted.

PS1589 RETROSPECTIVE ANALYSIS OF HEMOGLOBIN LEVEL IN 500 TRANSFUSION EVENTS AS A STUDY MODEL FOR THE EVALUATION OF TRANSFUSION APPROPRIATENESS

Background:The hemoglobin (Hb) value adopted in the real life setting for the clinical decision of packed red blood cell (RBC) transfusion (transfusion trigger) is sometimes difficult to accurately retrieve and could be different to what is indicated in the blood request. The identification of the transfusion trigger is critical for the analysis of the distinct physicians’ attitudes across the different units within the same hospital and for the dissection of transfusion appropriateness.Aims:The aims of the present analysis is to compare the transfusion trigger across the multiple medical and surgical units at our Center and to describe the Hb values before and after the transfusion events. Further, considerations about the feasibility and the potential applications of this analytical approach are discussed.Methods:Data extraction procedure focused on the first semester 2018, dealing with transfusion episodes of 1–2 packed RBCs administered to patients hospitalised at ASST GOM Niguarda, Milan, Italy. Each single episode was registered, regardless of the number of the total packed RBCs transfused, as well as the Unit where the patient was admitted and the Hb values at admission, before and after the transfusion, together with the respective date and time. Comparisons analyses were made using the classical statistical tests. The Hb value before the transfusion is considered as the trigger for transfusion decision by the physician(s) in charge of the patients.Results:On a total of n = 501 episodes, n = 497 were evaluable for completeness of data. The corresponding number of packed RBCs represents the 2% of all the packed RBCs transfused at our Hospital in one year (n = 22170 in 2018). Median Hb was 10.70 (range: 6.30–16.70), 8.60 (range:3.00–15.10) and 10.30 (range: 5.00–16.30) at admission, before and after transfusion, respectively. Analyzing separately by unit, we observed that the transfusion trigger was higher in Cardiac Surgery, Vascular Surgery and Intensive Care Units, with median values of 9.50, 8.75 and 8.70 respectively. Conversely, transfusion trigger was comparable among the other surgical units (including Orthopedics) and the medical ones: Hb median values were 8.20, 8.20 and 8.30 respectively. Cardiology showed a slightly higher trigger: 8.65 when compared with the other non‐surgical units.Summary/Conclusion:The present analysis, accounting for « only » the 2% of the total transfusion burden at our Hospital in 2018, allows for a satisfactory definition of the transfusion trigger across the multiple medical and surgical units as well as the confirmation of the expected post‐transfusion Hb values. Our analysis model supports the feasibility of such an approach as a potential audit instrument and intervention policies in the area.

Patient perceptions of peripheral artery disease: A cross-sectional study of hospitalized adults

Patients with peripheral artery disease (PAD) have increased risk for complications of cardiovascular disease. Smoking cessation, physical activity, and adherence to treatment are critical for limiting the progression of this chronic disease and improving health-related quality of life in patients with PAD.The aim of the study was to explore patient perceptions of PAD and views on medication, tobacco use, and physical activity. This descriptive, cross-sectional study included patients with PAD admitted to a vascular surgery unit at a tertiary academic medical center (October 2017 to January 2018). Sociodemographic data and medical information were collected during hospitalization. Patients completed the Brief Illness Perception Questionnaire, Beliefs about Medicines Questionnaire, and Cigarette Dependence Scale. Additional questions examined physical activity. In total, 32 patients participated in the study. About half (16/30) were active smokers, whereas the remainder had smoked in the past. Only half of patients (16/32) considered smoking as contributing to PAD. Most patients (18/30) perceived PAD as a chronic problem, yet 8/30 (27%) considered PAD a rather acute illness. Patients reported significant cognitive and emotional consequences of PAD (mean 6.2±1.8 and 8.3±2.9, maximum score 10, respectively). They rated relatively low perceived personal control (mean 4.8±2.8, maximum score 10) and weak beliefs about the necessity of medication (mean 12.5±3.3, maximum score 25). Most patients (21/32) perceived physical activity as a protective factor for PAD. Patients perceive PAD as having significant impact on their life and report low levels of personal control in managing PAD. Understanding patient health beliefs may inform more tailored therapeutic education and health promoting interventions to limit disease progression.

SUSCEPTIBILITY OF DIFFERENT REPRESENTATIVES OF THE GENUS CANDIDA TO ANTIMYCOTICS

Representatives of Candida.spp. demonstrate different susceptibility to azole compounds, which are widely used in the treatment of candidiasis. Due to the resistance to these compounds, C. glabrata remains in the body and, moreover, is able to multiply and increase its population. It quite often causes the development of nosocomial infections.&#x0D; The purpose of this study was to investigate the susceptibility of clinical strains of C. albicans and C. glabrata isolated from surgical patients to antifungal drugs.&#x0D; Materials and methods. We studied 5 clinical strains of C. albicans and 5 clinical strains of C. glabrata, taken from the patients of Thoracic and Vascular Surgery Units, V.M. Sklifosovskiy Poltava Regional Clinical Hospital.&#x0D; In order to assess the susceptibility of the studied clinical isolates to antimycotics, the method of two-fold serial dilutions (macrodilution) in liquid nutrient medium was used as the standard procedure according to the order of the Ministry of Public Health of Ukraine No. 167 dated April 05, 2007, on Approval of Guidelines “Assessment of Microbial Susceptibility to Antibacterial Drugs”. MIC was determined by the lowest concentration of the antifungal drug, which was able to suppress the visible growth of the studied microorganism culture. The presence of growth was assessed by inspecting the tubes in transmitted light compared to the “negative” control.&#x0D; To control the quality of evaluating susceptibility of microorganisms to antifungals, we used the reference strain Candida albicans CCM 885 taken from the Museum of Living Cultures of the Department of Microbiology, Virology and Immunology, UMSA. Testing of the control strain was carried out in accordance with the method described above in parallel with the study of clinical isolates. The findings obtained by evaluating the susceptibility (MIC) of the control strain were compared with the relevant parameters of its passport characteristics. If they match, the conditions of the experiment were considered as standard, and the results of evaluating sensitivity of clinical isolates obtained under these conditions were considered as reliable.&#x0D; To identify susceptibility of the genus Candida spp., natural anti-fungal agents of the polyene series (amphotericin B) and synthetic drugs of the azoles group (fluconazole, itraconazole) and pyrimidine derivatives (flucytosine) were used.&#x0D; Statistical analysis of the findings obtained was carried out using the standard software package "Microsoft Excel 2010". The presence of differences between the studied parameters was assessed by Student's t-test.&#x0D; Results and discussion. The study has demonstrated that the synthetic antifungal, flucytosine, has a low fungistatic effect on Candida spp. The presence of flucytosine inhibits the reproduction of the reference C. albicans strain at a concentration of 2 μg / ml. Along with it, clinical strains of yeast-like fungi of this genus were equally sensitive to flucytosine with a MIC of 3.2 ± 0.96 μ / ml. This indicates a low efficacy of this antimycotic for Candida spp.

The value of segmentation with 2D and 3D reconstruction before vascular surgery (about a case of aortic aneurysm)

Introduction: The development of digital research at the level of the anatomy laboratory with the vascular surgery unit by anatomo-radiological interpretation based on 2D segmentation and 3D reconstruction [1] using serial sections of medical imaging (angiogram) for the aortic aneurysms, realizes a fundamental element in the diagnosis approach and offers a panel of tools adapted to the constraints of the clinical practice to optimize the decision of the surgical act and the restoration of the function. The objective of this study is to highlight the anatomical reports of aneurysm to improve the management of a 68-year-old patient. Materials and methods: The 256 sections of a CT angiogram of a 68-year-old patient with aortic aneurysm for exploration of chest pain. The morpho-anatomical study of the thoraco-abdominal visceral structures, as well as the posterior mediastinal region and the aneurysmal dilatations at the level of the aortic vascular axis is performed by the 3D volume rendering technique using OSIRIX® software [2]. Results: Interactive 3d modeling of the aorta was achieved with volume quantification of the aneurysm. Discussion and conclusion: The three-dimensional volumetric modeling of an aneurysm in a 68-year-old patient visualizes the thoraco-abdominal aortic dilatation and the importance of the aneurysm in the mediastinum on 3D reconstruction images, hence the surgical or endovascular indication and the technical management [3].

Modified technique of end to side distal radio-cephalic shunt to overcome juxta-anastomotic stenosis

Background: Juxta-anastomotic stenosis (JAS) is one of the predominant causes of arteriovenous fistula (AVF) failure, with the reported incidence of 65%, so that technical modification to alter the outflow vein configuration using the modified technique has been applied to prevent JAS and improve AVF maturation. The aim of the study to evaluate the modified technique of end-to-side distal radiocephalic A-V fistula regarding maturation, patency rate and the resultant juxta-anastomotic stenosis.Methods: This prospective study was carried out on 80 patients with end stage renal disease (ESRD) at vascular surgery unit in general surgery department, Menoufia university hospital that prepared for dialysis. 40 patients "intervention group" underwent the modified technique to establish a functioning radiocephalic fistula; the other group (40 patients, control group) had the conventional technique of end to side radiocephalic fistula. Follow up of patients was over 6 months regarding function, patency rate and development of juxta-anastomotic stenosis.Results: There was statistically significant difference between 2 groups regarding primary failure, patency and JAS. Primary failure was detected in 2 patients in group A and in 5 patients in group B (p-value is 0.04). Considering patency rate, after 3 months the ratio between group A and group B was 37:34 with significant P value of 0.02, and after 6 months the ratio was 35:33 with P value of 0.03. Regarding JAS, by the end of follow up period, 4 patients diagnosed with JAS in group A, while group B had 8 patients, with p value of 0.01.Conclusions: Modified technique of end to side anastomosis for primary radio-cephalic fistula creation has better patency rate and low incidence of JAS than conventional method.

Analysis of the results of endovascular and open surgical treatment of acute limb ischemia

ObjectiveThe objective of this study was to evaluate the long-term estimates of limb salvage and survival in patients with acute limb ischemia (ALI) receiving open surgery or endovascular revascularization. MethodsThis was a retrospective consecutive cohort study of patients with ALI who underwent open surgery or endovascular treatment at the Vascular and Endovascular Surgery Unit, Hospital do Servidor Público Estadual (São Paulo, Brazil), between July 2010 and July 2016. The overall mortality, limb salvage, and survival rates at 720 days were analyzed in both the open surgery (group 1) and endovascular treatment (group 2) groups. ResultsA total of 69 patients were admitted for a limb salvage procedure. The mean follow-up period was 822 ± 480.5 days. All of the analyses were performed at 720 days. Of the 69 patients, 46 (66.6%) were in group 1 and 23 (33.4%) in group 2. The clinical characteristics were similar between the groups, except for higher rates of chronic kidney disease (P = .04) and arrhythmia (P = .01) in group 1. Group 1 had a higher postoperative ankle-brachial index (P = .03). Concerning the Rutherford classification, group 1 had a higher prevalence of Rutherford IIB ALI (P = .003). The preoperative creatine kinase level was higher in group 1 than in group 2 (780 [range, 198-6546] mg/dL and 245 [65-78] mg/dL, respectively). A creatine kinase level >200 mg/dL was seen in 65.2% and 47.8% of patients in group 1 and group 2, respectively (P = .028). The limb salvage and overall survival estimates at 720 days were similar between group 1 and group 2 (79.2% vs 90.6% [P = .27] and 53% vs 60.8% [P = .45], respectively). The overall mortality rate was 10.1% (seven patients) within the first 30 days, and it was higher in group 1 (six patients [13.0%]; P = .03). ConclusionsBoth open surgery and endovascular procedures are safe treatments of patients with ALI, with acceptable limb salvage and survival rates. No previous study has suggested the preferred treatment of ALI. However, based on this study and the overall literature, endovascular treatment may be the preferred treatment of patients with Rutherford I and IIA ALI; open surgery may be the best option for ALI due to arterial embolism and for Rutherford IIB acute arterial thrombosis because of a greater urgency to restore blood flow.

Comparative Study between Conventional Surgery and Radiofrequency Ablation in Treatment of Varicose Vein

Background: Varicose veins are a very common problem all over the world. Surgery has been the gold standard treatment for many years, however now other less invasive options are available and sometimes more efficient. Aim of the Work: To evaluate the RFA technique in treatment of GSV varicosities and to compare the results, clinical outcome, complications and recurrence rate after RFA and CS of GSV. Patients and methods: This observational retrospective study included 41 patients with varicose veins recruited from general surgery department and vascular surgery unit at Ain Shams Hospitals and in Nasser Institute for Research and Treatment. Results: Operative time was significantly less in CS compared to RFA. One , six and twelve months post intervention follow up using clinical examination and duplex imaging were used to asses outcome and detect complications and recurrence rate. No major complications were detected after both techniques; however minor post operative complications like paresthesia and ecchymosis were significantly less after RFA. Post operative pain, duration of analgesia use and time needed to return to normal activity were also significantly less in RFA group than CS group. Recanalization of GSV was not detected after radiofrequency maneuver nor CS. This study proved that radiofrequency ablation technique is safe and efficient in treating varicose veins however long-term results and cost effectiveness need further evaluation. Conclusion: Conventional surgery has been used for a long time for treatment of varicose veins with variable degrees of minor to major complications. Duplex guided radiofrequency ablation is an efficient and a safe modality in the treatment of great saphenous vein varicosities. Of most importance is an adequate Duplex scan to identify accessory channels and double superficial systems.

Nutritional status of patients admitted to a metropolitan tertiary care vascular surgery unit.

Undernutrition in vascular surgery patients has a significant impact on clinical outcomes. This observational study aimed to investigate the nutritional status of a heterogeneous sample of vascular surgery inpatients and to determine the prevalence of nutritional risk, malnutrition (including nutrient deficiencies) and sarcopenia. All participants were screened for risk of malnutrition using the Malnutrition Universal Screening Tool (MUST) and assessed using the Patient-Generated Subjective Global Assessment (PG-SGA). Micronutrient status was examined via plasma/serum samples. The presence of sarcopenia was explored using an accepted algorithm incorporating gait speed, muscle mass (DEXA) and grip strength. 322 participants (69% male, mean age 67.6±14.1y) consented to the study. 12.5% were identified as at risk of malnutrition by the MUST while 15.8% were deemed malnourished by the PG-SGA. Only 5% were diagnosed as sarcopenic. Prevalence of malnutrition was much higher when micronutrients were examined with 79% showing low vitamin C, 56% low vitamin D and over 40% having low zinc, vitamin B-12 and folate. A smaller proportion were also low in selenium (19%). Patients with vascular disease are a nutritionally vulnerable group. The MUST and PG-SGA did not identify the full extent of nutritional deficiencies. Further investigation is warranted to assess tool validity in this group. A number of micronutrients are crucial in these patients and hence a more comprehensive assessment that encompasses a wider range of parameters, including micronutrient status appears warranted.

Short term outcome of retrograde tibiopedal access in management popliteal and infrapopliteal disease

Background: Aim was to evaluate the safety and efficacy of retrograde tibiopedal access after failed antegrade recanalization in patients with femero-popliteal and infrapopliteal occlusions.Methods: This is a retrospective study including patients presenting with critical limb ischemia due to femero-popliteal and infrapopliteal occlusions for whom retrograde transpedal/tibial access was used after failure of antegrade approach at the vascular surgery unit in Kasr Al Aini hospitals in the period from June 2015 to June 2017.Results: The study included 18 patients with a mean age of 64 years and male to female ratio 2.6:1. All patients presented with CLI (Rutherford category 4-6), all lesions were Trans Atlantic Society Consensus (TASC) II D, and Technical success was accomplished in 17 cases (94.4 %). In one case, failure to cross the target lesion via both antegrade and retrograde accesses occurred and the patient was immediately converted to an open surgery (popliteal tibial bypass). Complications included 2 puncture site hematoma that were managed conservatively; no AVF. There was no perioperative mortality. Primary patency was 81.25 % at 6 month.Conclusions: retrograde tibiopedal access is safe and effective technique after failed antegrade recanalization in patients with popliteal and infrapopliteal occlusions.

Anaemia in patients who underwent vascular surgery: A significant predictor of amputation and death

Background and objectiveIn patients with peripheral artery disease requiring surgery, anaemia has been found to independently predict short and medium term higher morbidity and mortality. Patients and methodsWe retrospectively studied all patients undergoing surgery, consecutively during 2 months in 12 vascular surgery units. We analyzed cardiovascular risk factors and preoperative hemoglobin. Statistical analysis was done with Kaplan–Meier for survival and logistic regression modeling to identify predictors of mortality. Results518 patients were consecutively operated on in our vascular units, the mortality rate was 21% the first year and 34% for cardiovascular events. Preoperative anaemia was present in 63% of the ischemic patients and in 23% of the patients requiring aneurysm repair, one year after surgery it increased to 68% and 50% respectively.When preoperative anaemia was superior to 10mg/dl, one year survival increased (96% vs. 90%), fewer cardiovascular events occurred and there were fewer amputations (24% vs. 68%). ConclusionsOn multivariable analysis: age, renal failure, chronic lung disease, coronary artery disease, postoperative complications and previous cardiovascular events were associated with an increased risk mortality rate. Preoperative hemoglobin influenced proportionally such that for every 1mg/dl increase, the probability of mortality decreases by 0.81. Preoperative anaemia, especially when hemoglobin is inferior to 10mg/dl, is associated with an increased risk of death and amputation.

Conventional method versus no-touch technique in radiocephalic arteriovenous fistula

Objectives The aim was to evaluate the feasibility of no-touch technique (NTT) in radiocephalic fistula and to compare conventional method with NTT in the creation of radiocephalic fistula regarding the rate of complication, failure of maturity, and patency rate. Background Radiocephalic fistula is consider the first fistula to be created; however, it has a higher failure rate. NTT represents an attractive option for performing radiocephalic fistula. Patients and methods This is a prospective comparative study done on 80 patients with end-stage renal disease who were prepared for dialysis. Half of the patients were operated by NTT and the other half by conventional technique at vascular surgery unit in department of general surgery, Menoufia University Hospital, between November 2016 and April 2018. Results A total of 80 patients who had end-stage renal disease underwent radiocephalic arteriovenous fistula: half of them with conventional (Brescia and Cimino) technique and the other half with no-touch method. The primary failure rate in NTT (7.5%) was not statistically significantly different from the conventional method (17.5%). The primary patency also had no statistically significant difference during the follow-up period at 1 and 3 months between the two methods, but NTT at 6 months had better primary and secondary patency rates than conventional method. There was no difference in infection and pseudoaneurysm rates between the two methods. Conclusions The results of this study indicate that NTT can be used for primary radiocephalic fistula surgery and showed better results than conventional method in the long-term follow-up.

Predictive value of angiographic characteristics for endovascular revascularization of ischemic diabetic foot

Background Endovascular techniques have undergone major advances with regard to the treatment of infrapopliteal arterial occlusive disease. Objective The objective of this study was to determine angiographic characteristics of infrapopliteal arterial lesions that are dependent predictors of endoluminal revascularization in diabetic patients with ischemic foot ulcers. Patients and methods The present study included 64 patients with ischemic diabetic foot ulcers who were admitted to the vascular surgery unit at Gamal Abdel Naser Hospital (Alexandria) during October 2014–December 2015. Informed consent was obtained from all patients. Patients underwent angioplasty and were followed-up for an average of 12 months. The clinical and procedural data of all included patients were collected. Preprocedural and postprocedural angiographic images were reviewed to classify lower-limb arterial involvement according to the Joint Vascular Society Council classification of calf and foot scores. Foot lesions were graded according to The University of Texas wound classification system. Clinical results (healing, nonhealing, or major amputation) were compared with baseline clinical data and angiographic results using Student's t test. All statistical analyses were performed using SAS software. Results During the study period, 64 percutaneous procedures were performed, with an immediate technical success rate of 89.8%. Before the procedure, the mean ± SD calf and foot scores were 7.8 ± 1.6 and 7.3 ± 2.3, respectively. After the procedure, the mean calf and foot scores were 4.8 ± 2.3 and 5.9 ± 2.6, respectively. The limb salvage rate was 87%, and the major amputation rate was 9.4%. Among all the clinical and angiographic variables included in the analysis, only preprocedural and postprocedural foot scores were significantly associated with the clinical outcome (P Conclusion Preprocedural and postprocedural foot scores represent the most significant angiographic parameters to evaluate chances for ulcer healing, and consequently to determine the success of the revascularization procedure.

Delayed Presentation Of Missed Vascular Injuries And Pitfalls In Primary Treatment– Experience Of A Vascular Surgery Unit In Pakistan

Objective: To analyze errors in primary treatment of vascular injuries and delayed presentations of missed vascular injuries as a surrogate indicator of need for improved vascular surgical training of upcoming general surgeons. Materials and methods: This retrospective observational study was carried out at vascular surgery department of two tertiary care hospitals of Armed Forces from Jan 2012 to June 2017. Hospital records of all patients with vascular trauma were analyzed for presence of pitfalls in primary treatment and delayed presentation of missed vascular injuries which resulted in redo surgeries or adverse outcomes. Results: Out of 256 patients with vascular injury sequel 41 had either a problem in primary treatment or presented with delayed complications of missed injuries. The omissions can be divided into: missed injuries (24/41), technical errors in initial repair (12/24), reperfusion of mangled Extremity (3/41) and non availability of a surgeon capable of undertaking vascular repair. The commonest operative fault was failure to debride the vessel adequately and vascular repair under tension. The commonest primary assessment problem was failure to timely appreciate hard signs of vascular injury. Conclusion: With better training and emphasizing the need of thorough clinical examination outcome of vascular trauma can be improved.

Proyecto ARPA: Arteterapia con personas amputadas. Resultados, reflexiones ético-metodológicas y conclusiones del estudio

El proyecto Arpa es un estudio piloto de investigación cuantitativa llevado a cabo en la Unidad de Cirugía Vascular del Hospital del Mar y centro Fórum de Barcelona durante los años 2016 y 2017. En el presente artículo se expone el desarrollo, resultados y limitaciones del mismo, así como las dificultades encontradas y las cuestiones ético-metodológicas derivadas.El estudio ha ofrecido sesiones de Arteterapia a 9 personas intervenidas quirúrgicamente por una amputación. Los resultados obtenidos muestran mejoras en síntomas de depresión y autoimagen y datos contradictorios en autoestima y respuestas psicológicas de duelo. El cuestionario diseñado por el equipo indica una satisfacción alta aunque inespecífica de la atención recibida.Se concluye la presencia de efectos positivos, si bien son necesarios estudios con muestras de mayor tamaño y rigurosidad en su metodología.

Damage to vessels and retroperitoneal organs during lumbar spine surgery through the posterior approach

The study objective is to summarize the existing literature and own experience related to damage to vessels, retroperitoneal organs, and abdominal organs during lumbar spine surgery through the posterior approach, as well as to identify risk factors associated with this damage and to describe measures for their elimination and prevention.Materials and methods. In addition to analyzing the research literature, we also described 9 cases (3 males and 6 females; mean age 52 ± 9 years) of intraoperative damage to vessels and adjacent organs during lumbar spine surgery for some degenerative disease, including herniated disc (n = 7), anterolisthesis (n = 1), and vertebral-motor segment instability (n = 1). The surgery was performed at the L4–L5 level (n = 7) and L5–S1 level (n = 2). Results. The damages observed in the cohort analyzed were caused by a conchotome (n = 6), transpedicular screw (n = 1), Volkmann spoon (n = 1), and a tip of the SpineJet Hydrodiscectomy System (n = 1). The following structures were damaged; left common iliac vein (n = 2), left common iliac artery (n = 2), left common iliac vein and root of the small-bowel mesentery (n = 1), sigmoid colon (n = 1), aorta (n = 1), inferior vena cava (n = 1), and aortocaval anastomosis (n = 1). Five patients had intraoperative hemorrhagic complications. Four patients were found to have damage to vessels or abdominal organs later (1 h, 2 h, 3 days, and 4 months postoperatively). Four patients were discharged without consequences; 2 patients became disabled; 3 patients died.Conclusion. Damage to vessels, retroperitoneal organs, and abdominal organs during lumbar spine surgery through the posterior approach is a rare, but mortally dangerous complication. Spine surgery should be performed in multi-unit hospitals that have a surgery unit, a vascular surgery unit, an intensive care unit, and a sufficient supply of blood for transfusion.

Introducing a Clinical Documentation Specialist to Improve Coding and Collectability on a Surgical Service.

Inadequate electronic medical record (EMR) documentation remains a significant source of revenue loss. The Department of Surgery in a trauma and tertiary care teaching hospital developed a revenue optimization initiative for inpatients on general, vascular, and trauma surgery and surgical intensive care unit services to enhance clinical documentation and increase revenue capture. Clinical documentation management program included six trained clinical documentation specialists (CDSs), five physician assistants (PAs), directors of health information management (HIM), and two surgical champions. Lean methodology was applied to develop a coding and documentation program wherein trained CDS polled ICD-10 codes in the surgical EMR for accuracy in diagnoses documentation. An opportunity for improved documentation prompted query generation for a specially trained PA review. Physician assistant adjusted EMR documentation according to query to more accurately describe high impact diagnoses. Outcomes included PA query response rate, potential revenue opportunities, validated revenue gains, and missed revenue opportunity. Twelve thousand EMRs were queried in the study interval. $2,206,620.16 in validated revenues were realized. Interestingly, we identified $1,792,591.91 in potential opportunities and $65,097.30 in lost opportunities. Query response rate increased from 17% to 94.7%. The authors demonstrate a concentrated Coding and Documentation Program involving CDS, and Surgical PAs results in significant revenue gains for an inpatient surgery service in a public hospital.

Risk factors associated with amputation in civilian popliteal artery trauma

Popliteal artery trauma is uncommon but is associated with a high risk of limb loss depending on the scenario involving blunt or penetrating trauma as well as the severity and extent of injury that has occurred. In our setting there is a significant amount of gang and civilian warfare resulting in Vascular Trauma. There were 32 patients over a decade who sustained traumatic injury to the popliteal artery consisting of 30 males (94%) and 2 females with an age range 16–59 years with a mean of 32. There were 20 cases of penetrating trauma (63%) and 12 cases of blunt trauma (37%). Of the penetrating trauma, 18 were due to gunshot wounds (GSWs) (90%) and 2 stabs. The majority (7/12; 58%) of blunt trauma was due to falls, and 42% (5/12) secondary to motor vehicular accidents (MVAs). In terms of extent of injury, 21 of 32 patients (65%) sustained an isolated popliteal artery injury, whilst 6 (19%) had injury to both the popliteal artery and vein and another 5 (16%) had combined popliteal artery, vein and nerve injuries. There were 14 cases with associated orthopaedic injuries: 7 posterior knee dislocations, 1 fracture/dislocation of the knee, 2 femoral fractures, 2 tibial plateau fractures and 2 tibia/fibula fracture. Methods of repair included 14 reversed vein grafts, 16 polytetrafluoroethylene (PTFE) grafts and 2 primary. The overall amputation rate was 28% (9 patients). Of the penetrating trauma patients 25% required amputations composed of 5 GSWs, 33% of the blunt trauma patients required amputations. It was noted that factors associated with (but not statistically significant) poor outcomes included combined artery/vein injury, artery/vein/nerve injury, concomitant fracture/dislocation and delayed transfer to a Vascular Surgery Unit. The type of graft or repair did not affect outcome. The incidence of popliteal artery trauma was calculated at 2.46 per 100,000 population per year.