Venous Injury Research Articles

Vascular Reconstruction and Limb Loss in Military Tibial Artery Injuries

Selective operative management of injuries to the tibial arteries is controversial, with the necessity of revascularization in the face of multiple tibial arteries debated. Tibial artery injuries are frequently encountered in military trauma, but revascularization practices and outcomes are poorly defined. We aimed to investigate associations between the number of injured vessels and reconstruction and limb loss rates in military casualties with tibial arterial trauma. A US military database of lower extremity vascular injuries from Iraq and Afghanistan (2004-2012) was queried for limbs sustaining at least 1 tibial artery injury. Injury, intervention characteristics, and limb outcomes were analyzed by the number of tibial arteries injured (1, T1; 2, T2; 3, T3). Two hundred twenty one limbs were included (194 T1, 22 T2, 5 T3). The proportions with concomitant venous, orthopedic, nerve, or proximal arterial injuries were similar between groups. Arterial reconstruction (versus ligation) was performed in 29% of T1, 63% of T2, and universally in T3 limbs (P<0.001). Arterial reconstruction was via vein graft (versus localized repair) in 62% of T1, 54% of T2, and 80% of T3 (P=0.59). T3 received greater blood transfusion volume (P=0.02), and fasciotomy was used universally (versus 34% T1 and 14% T2, P=0.05). Amputation rates were 23% for T1, 26% for T2, and 60% for T3 (P=0.16), and amputation was not significantly predicted by arterial ligation in T1 (P=0.08) or T2 (P=0.34) limbs. Limb infection was more common in T3 (80%) than in T1 (25%) or T2 (32%, P=0.02), but other limb complication rates were similar. In this series of military lower extremity injuries, an increasing number of tibial arteries injured was associated with the increasing use of arterial reconstruction. Limbs with all 3 tibial arteries injured had high rates of complex vascular reconstruction and eventual amputation. Limb loss was not predicted by arterial ligation in 1-vessel and 2-vessel injuries, suggesting that selective reconstruction in these cases is advisable.

Anterior Petrosectomy With Intertentorial Approach.

The extradural anterior petrosal approach (EAPA) can present a challenge because it deals with critical structures in a narrow, confined corridor. It is associated with several potential approach-related risks including temporal lobe and venous injuries. Tentorial peeling has the potential to largely eliminate these risks during the approach and may offer more options for tailoring the dural opening to the anatomic region that one wants to expose. Anatomic dissections of five adult injected non-formalin-fixed cadaveric heads were performed. Anterior petrosectomy with intertentorial approach (APIA) through a tentorial peeling was completed. Step-by-step documentation of the cadaveric dissections and diagrammatic representations are presented along with an illustrative case. Tentorial peeling separates the tentorium into a temporal tentorial leaf and posterior fossa tentorial leaf, adding a fourth dural layer to the three classic ones described during a standard EAPA. This opens out the intertentorial space and offers more options for tailoring the dural incisions specific to the pathology being treated. This represents a unique possibility to address brainstem or skull base pathology along the mid- and upper clivus with the ability to keep the entire temporal lobe and basal temporal veins covered by the temporal tentorial leaf. The APIA was successfully used for the resection of a large clival chordoma in the illustrative case. APIA is an interesting modification to the classic EAPA to reduce the approach-related morbidity. The risk reduction achieved is by eliminating the exposure of the temporal lobe while maintaining the excellent access to the petroclival region. It also provides several options to tailor the durotomies based on the localization of the lesion.

Combined Arterial and Venous Lower Extremity Injury

This case-control study assesses the need for prophylactic fasciotomy and delayed fasciotomy in combined arterial and venous injury compared with those with isolated artery or vein injury.

The Role for Preperitoneal Pelvic Packing in Low-to-Middle-Income Countries: A 16-Year Experience at a Johannesburg Trauma Unit.

Preperitoneal pelvic packing for early pelvic haemorrhage control reduces mortality. Bleeding noted with pelvis fractures is predominantly due to associated venous complex injuries. More studies are advocating for angiography as first-line therapy for haemodynamic instability in pelvic fractures; however, these facilities are not in abundance in middle- and low-income countries. We hypothesized that PPP improves outcomes under these circumstances. Retrospective analysis of data from the patients charts over a period of 16years from 01 January, 2005 to 31 December, 2020. All patients over the age of 18years who presented with haemodynamic instability from a pelvic fracture and required PPP were included. The demographics, physiological parameter in emergency department, blood products transfused, morbidity and mortality were analysed. There were 110 patients identified in the study period who underwent pelvic preperitoneal packing for refractory shock or ongoing bleeding. The majority (75.5%) of patients were men (n = 83). The median age was 38years. The most common mechanism of injury was pedestrian vehicle collision (51%), followed by motor vehicle collisions (27.3%). The median ISS and NISS were 35 and 40, respectively. The median RTS in ED was 4.8(3-6.8). None of our patients rebleed after pack removal and no one needed repacking or adjunct angioembolization in our study group. The in-hospital mortality rate was 43.6% (n = 48) in patients who underwent preperitoneal pelvic packing. The operating room table mortality was 20% (n = 22/110), and the mortality rate of those who survived to ICU transfer was 29.5% (n = 26/88). Pelvic preperitoneal packing has a role in the acute management of haemodynamically abnormal patients with pelvic fractures in our environment. In the absence of immediate angioembolization, preperitoneal packing can be lifesaving.

Dehydrated human amnion/chorion membrane allograft with spongy layer to significantly improve the outcome of chronic non-healing wounds.

We investigated the healing effect of a new dehydrated amnion/chorion membrane with a spongy layer over a 30-month period in 32 patients with 53 chronic non-healing wounds of different aetiologies. Wounds with <40% surface reduction after 4 weeks of best wound treatment underwent weekly allograft application by a certified wound specialist based on national guidelines and a standardised protocol until complete healing or definite treatment interruption. The main outcome measure was the percentage of wound surface reduction from baseline calculated using digital planimetry follow-up photographs. Overall, 38 (71.7%) wounds presented a favourable outcome (70%-100% area reduction), with 35 (66%) completely healing over a median time of 77 days (range 29-350 days). Favourable outcomes were observed in 75% of traumatic wounds, surgical wounds, venous leg ulcers and pressure injuries, as well as in 50% of ischaemic wounds. Wounds being present <12 months were significantly more likely to have a favourable outcome than more long-standing wounds (χ2 = 7.799; p = 0.005; OR = 3.378; 95% CI, 1.410-8.092). Thus, treatment with dehydrated amnion/chorion membrane with a spongy layer improves the outcome of non-healing wounds of different aetiologies and, therefore, has to be considered early in the management of refractory wounds.

Loss of 12-Lipoxygenase Improves the Post-Transfusion Function of Stored Platelets.

Platelets for transfusion are stored for 5 to 7 days. Previous studies have shown that HETE levels in the storage bag negatively correlate with platelet performance in vivo, suggesting that the dysregulation of bioactive lipid mediators may contribute to the storage lesion. In the current study, we sought to understand how genetic deletion and pharmacological inhibition of 12-LOX (12-lipoxygenase) affects platelets during storage and after transfusion. Platelets from 12-LOX+/+ (wild-type [WT]) and 12-LOX-/- mice were stored for 24 and 48 hours and profiled using liquid chromatography-tandem mass spectrometry-multiple reaction monitoring or transfused into thrombocytopenic hIL4R (human interleukin 4 receptor)-transgenic mice. Platelet function was assessed by flow cytometry and in vivo thrombosis and hemostasis models. To test the role of the COX-1 (cyclooxygenase-1) pathway, donor mice were treated with acetylsalicylic acid. Human platelets were treated with the 12-LOX inhibitor, VLX-1005, or vehicle, stored, and transfused to NOD/SCID (nonobese diabetic/severe combined immunodeficiency) mice. Polyunsaturated fatty acids increased significantly in stored platelets from 12-LOX-/- mice, whereas oxylipin concentrations were significantly higher in WT platelets. After transfusion to thrombocytopenic mice, we observed significantly more baseline αIIbβ3 integrin activation in 12-LOX-/- platelets than in WT platelets. Stored platelets from 12-LOX-/- mice occluded vessels significantly faster than stored WT platelets. In hemostasis models, significantly more stored 12-LOX-/- than WT platelets accumulated at the site of venous injury leading to reduced blood loss. Inhibition of COX-1 abrogated both increased integrin activation and thromboxane generation in stored 12-LOX-/- platelets, highlighting the critical role of this pathway for improved post-transfusion function. Consistent with our mouse studies, human platelets stored with VLX-1005, showed increased integrin activation compared with vehicle-treated platelets after transfusion. Deleting 12-LOX improves the post-transfusion function of stored murine platelets by increasing thromboxane generation through COX-1-dependent arachidonic acid metabolism. Future studies should determine the feasibility and safety of 12-LOX-inhibited platelets transfused to humans.

Traumatic Cranial Dural Venous Sinus Injury

Purpose: The study's objective is to elucidate and discuss the causes of traumatic dural venous sinus injury and make comparisons between these causes. The aim is also to assess the susceptibility of dural sinuses to injury in descending orders. Additionally, the research examines the relationship between types of fracture and the challenges in controlling bleeding in patients with traumatic dural venous sinus injury. Furthermore, the study analyzes the factors that influence the morbidity and mortality rate among patients with traumatic dural venous sinus injury. Methodology: Between January 2021 and October 2022, a prospective study was carried out, involving 22 patients diagnosed with dural venous sinus injury. The study encompassed both surgically and conservatively treated patients. For each participant, demographic information, such as age, sex, causative trauma, preoperative GCS, preoperative deficit, image findings, name, and part of the injured sinus, as well as the presence and absence of a fracture and its relation to the sinus were recorded. The intraoperative method employed to control bleeding and the amount of blood transfusion were also documented, along with postoperative GCS and postoperative complications. The Glasgow Coma Scale (GCS) score was utilized to assess the neurological outcome. Findings: The most frequently injured dural venous sinus was the superior sagittal sinus, accounting for 77.3% of cases (8).Among patients with a linear skull fracture crossing the venous sinus, 83.3% had bleeding that could be easily controlled by placing Gelfoam over the injured sinus . However, in patients with a skull fracture parallel to the sinus over the venous sinus and those with depressed fractures (with/without penetration), we encountered greater difficulty in controlling bleeding (14). Only 16.7% and 10% of these cases, respectively, were easily controlled by placing Gelfoam over the injured sinus, necessitating additional techniques to control bleeding in the remaining patients. Out of the total patients, 20 were managed surgically, while two were managed conservatively due to a Glasgow Coma Scale (GCS) score of 3 and signs of brain death. Unique Contributions to Theory, Policy and Practice: The superior sagittal sinus was identified as the most commonly injured sinus. Road traffic accidents (RTAs) accounted for the most frequent cause of dural sinus injury, representing 40.9% of cases. Bleeding control proved more challenging when dealing with linear fractures parallel to the sinus or depressed (and/or penetrating) fractures over the sinus, compared to linear fractures crossing the sinus. The most significant factor influencing the mortality rate was the Glasgow Coma Scale (GCS) score on admission. Mortality and morbidity rates were highest in cases involving injury to the posterior part of the superior sagittal sinus, sigmoid sinuses, and combined injury to the anterior and middle parts of the superior sagittal sinus. Furthermore, the mortality rate was notably higher among military-injured patients than civilian-injured patients

Medicolegal Implications of Vascular Trauma: An Institutional Experience

Background: Vascular trauma is one of the devastating types of injuries . Despite this fact, there is an obvious deficiencyin the educational sessions for vascular surgeons concerning the appropriate medicolegal dealing with such injuries.Aim: To highlight the role of vascular limb trauma during present scenario with the medicolegal and clinicalfindings.Methods: A 5 -years retrospective study with a follow up period of 2 years studying the data of peripheral vascularinjuries at three specialized trauma centre with special emphasize on the cause, the type, and the outcome of thistrauma . Obtained data were statistically analysed using the SPSS computer program (version 23).Results: This study included 1550 trauma patients (987 males and 563 females) who presented with peripheralvascular injuries. The patients’ age ranged from &lt; 3 years to &gt;70 years. There was a significant associationbetween the age and the circumstances of trauma. The most encountered causative mechanisms were trafficaccidents (45.7%) and firearms (21.7%). There was no significant association between outcome and age (p =0.114) or circumstances of trauma (p = 0.208). There was a highly significant association between the outcomeand the duration of hospital stay (p &lt; 0.001). Lower limb injuries were higher in frequency than upper limbinjuries (n = 286 and 123) respectively. Upper and lower limbs arterial injuries had a significantly higherfrequency rate than the venous injuries. Ulnar artery and brachial vein injuries was the most frequentlyencountered upper limb arterial and venous trauma, while the femoral artery and the deep femoral vein werefound to be the most affected lower limb vessels. Bone injuries were the most frequently accompanying injuries(44.6% of total cases).Conclusion: As any sort of injury may possess medical and lawful perspectives, medicolegal investigations havevery important position when studying trauma cases, going hand in hand with the clinical aspect.

Dural sinus septum: an underlying cause of cerebral venous sinus stenting failure and complications

ObjectivesThe presence of dural sinus septum has long been identified anatomically but is often neglected for its clinical significance. Our findings revealed the association of dural sinus septum with venous...

Use of tubular retractors to access deep brain lesions: A case series

BackgroundDeep-seated intracranial lesions can be accessed using blade retractors that may disrupt white matter tracts, exert pressure on adjacent tissue, and lead to post-operative venous injury. Tubular retractors may minimize disruption to white matter tracts by radially dispersing pressure onto surrounding tissue. This study characterizes perioperative outcomes in patients undergoing biopsy or resection of intracranial pathologies using tubular retractors. MethodsAdult patients (≥18 years) undergoing neurosurgical intervention using tubular retractors at a single health system (January 2016-February 2022) were identified through chart review. Demographics, disease characteristics, management data, and clinical outcomes were collected. ResultsA total of 49 patients were included; 23 (47%) had primary brain tumors, 8 (16%) metastases, 6 (12%) intracranial hemorrhage (ICH), 5 (10%) cavernomas, and 7 (14%) other pathologies. Lesions were located subcortically (n = 19, 39%), intraventricularly (n = 15, 31%), and in deep gray matter (n = 11, 22%). Gross total resection (GTR) or near GTR was achieved in 21 of 26 (80.8%) patients with intracranial lesions where GTR was the goal of surgery; 10 of 11 (90.9%) biopsies in patients with masses were diagnostic. Five of six (83.3%) ICHs were totally or near totally evacuated. Seventeen patients (35%) had major complications post-operatively. The most common complications were DVT/PE (n = 7, 14%) and seizures (n = 6, 12%). For patients who experienced post-operative seizures, 3 had seizures preoperatively and 1 had seizures in the context of electrolyte derangements. No patients died of post-operative complications. ConclusionThis operative approach may facilitate safe and efficacious biopsy or resection of deep-seated intracranial pathologies.

The Pathophysiology, Identification and Management of Fracture Risk, Sublesional Osteoporosis and Fracture among Adults with Spinal Cord Injury.

The prevention of lower extremity fractures and fracture-related morbidity and mortality is a critical component of health services for adults living with chronic spinal cord injury (SCI). Established best practices and guideline recommendations are articulated in recent international consensus documents from the International Society of Clinical Densitometry, the Paralyzed Veterans of America Consortium for Spinal Cord Medicine and the Orthopedic Trauma Association. This review is a synthesis of the aforementioned consensus documents, which highlight the pathophysiology of lower extremity bone mineral density (BMD) decline after acute SCI. The role and actions treating clinicians should take to screen, diagnose and initiate the appropriate treatment of established low bone mass/osteoporosis of the hip, distal femur or proximal tibia regions associated with moderate or high fracture risk or diagnose and manage a lower extremity fracture among adults with chronic SCI are articulated. Guidance regarding the prescription of dietary calcium, vitamin D supplements, rehabilitation interventions (passive standing, functional electrical stimulation (FES) or neuromuscular electrical stimulation (NMES)) to modify bone mass and/or anti-resorptive drug therapy (Alendronate, Denosumab, or Zoledronic Acid) is provided. In the event of lower extremity fracture, the need for timely orthopedic consultation for fracture diagnosis and interprofessional care following definitive fracture management to prevent health complications (venous thromboembolism, pressure injury, and autonomic dysreflexia) and rehabilitation interventions to return the individual to his/her pre-fracture functional abilities is emphasized. Interprofessional care teams should use recent consensus publications to drive sustained practice change to mitigate fracture incidence and fracture-related morbidity and mortality among adults with chronic SCI.

Prevention of thrombotic complications in patients in the postoperative period of total hip and knee arthroplasty: efficacy and safety

Thromboembolic complications (TEC) remain a significant problem in modern surgery, worsening the prognosis and reducing the effectiveness of the operation performed. The increase in the number of venous thromboembolisms (VTE) is determined by the severity of the initial injuries, the volume and traumatic nature of the surgical intervention, as well as the increase in the number of elderly patients with multiple comorbidities. Patients in orthopedic departments who have undergone major surgeries such as total hip arthroplasty (THA) or total knee arthroplasty (TKA) are at increased risk of VTE, leading to significant postoperative morbidity and mortality. Thromboses in extensive orthopedic surgery are caused by several prothrombotic mechanisms, such as venous injury, activation of procoagulation factors due to massive bone and tissue damage, and prolonged postoperative immobilization. The most common potential thrombotic complications after arthroplasty are deep vein thrombosis (DVT) of the lower extremities and pulmonary embolism (PE).In the absence of prophylaxis in the postoperative period of major orthopedic surgeries, TECs develop in most patients.To date, the issue of primary prevention of VTE in orthopedic patients remains relevant, and there is still no consensus on the best way to prevent thrombosis after THA and TKA.Risk assessment is the first step in preventing death and disability from VTE. Currently, mechanical and pharmacological methods are used for primary prevention in orthopedics, often in combination. Certainly, the use of antithrombotic drugs in the postoperative period is an effective way to prevent thrombosis. When prescribing antithrombotic drugs, it is also important to minimize the risk of bleeding, including in the area of postoperative wounds. Various antithrombotic drugs are used as pharmacological prophylaxis for TEC. The literature on the dosage, duration, efficacy, and safety of their use varies considerably. Our review assessed published literature on the efficacy and safety of antiplatelet agents for VTE prophylaxis.

Management of Inflammatory Aortic Aneurysms – A Scoping Review

Inflammatory abdominal aortic aneurysms (InflAAAs) account for 5 – 10% of aortic aneurysms and are characterised by retroperitoneal fibrosis. Diagnosis is often delayed, and doubts remain about the optimal management strategy. This scoping review describes the current state of knowledge on InflAAAs. Medline, PubMed, EMBASE, and Scopus were searched for relevant studies that evaluated the diagnosis and treatment of InflAAAs. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol was followed. Fifty-seven papers were selected (low level of evidence), which included 1 554 patients, who were mostly male and heavy smokers. A triad of chronic abdominal or back pain, weight loss, and elevated inflammatory markers was highly suggestive of the diagnosis but rarely present, and fever was noted only randomly. A mantle sign was seen on computed tomography angiography (CTA) in 73 – 100% of patients. Open surgical repair (OSR) and endovascular aortic aneurysm repair (EVAR) was reported in 1 376 and 178 patients, respectively. OSR was associated with significant iatrogenic bowel (n = 22), urinary tract system (n = 7), venous (n = 30), pancreatic (n = 6), and splenic (n = 5) injuries, while EVAR was associated with lower 30 day mortality (0 – 5% vs. 0 – 32%). One and two year mortality rates were similar between the two treatment modalities (0 – 20% and 0 – 36%, respectively). EVAR was more often associated with post-operative progression of inflammation (17% vs. 0.4%), and a higher frequency of persistent hydronephrosis (> 50%) and limb occlusion (20%). Used in < 10% of patients, corticosteroids led to complete pain relief and a reduction in peri-aortic inflammation within 6 – 18 months. InflAAAs are characterised by non-specific symptoms, with the mantle sign on CTA being pathognomonic. Corticosteroids may be considered a basic treatment that all patients should receive initially. Low quality data indicate that EVAR (vs. OSR) is associated with fewer intra-operative complications and lower peri-operative mortality but more late fibrosis related adverse events. International multicentre registries are required to gather more insights into this challenging pathology.

Vascular Reconstruction and Limb Loss in Military Tibial Artery Injuries

Selective operative management of injuries to the tibial arteries is controversial, with the necessity of revascularization in the face of multiple tibial arteries debated. Tibial artery injuries are frequently encountered in military trauma, but revascularization practices and outcomes are poorly defined. We aimed to investigate associations between the number of injured vessels and reconstruction and limb loss rates in military casualties with tibial arterial trauma. A US military database of lower extremity vascular injuries from Iraq and Afghanistan (2004-2012) was queried for limbs sustaining at least one tibial artery injury. Injury and intervention characteristics and limb outcomes were analyzed by the number of tibial arteries injured (one, T1; two, T2; three, T3). We included 221 limbs (194 T1, 22 T2, 5 T3). The proportions with concomitant venous, orthopedic, nerve, or proximal arterial injuries were similar between groups. Arterial reconstruction (vs ligation) was performed in 29% of T1, 63% of T2, and universally in T3 limbs (P < .001) (Figure). Arterial reconstruction was via vein graft (vs localized repair) in 62% of T1, 54% of T2, and 80% of T3 (P = .59). T3 received greater blood transfusion volume (P = .02) and fasciotomy was used universally (vs 34% T1 and 14% T2; P = .05). Amputation rates were 23% for T1, 26% for T2, and 60% for T3 (P = .16), and amputation was not significantly predicted by arterial ligation in T1 (P = .08) or T2 (P = .34) limbs. Infection was more common in T3 (80%) than T1 (25%) or T2 (32%, P = .02), but other limb complication rates were similar. In this series of military lower extremity injuries, an increasing number of tibial arteries injured was associated with increasing use of arterial reconstruction. Limbs with all three tibial arteries injured had high rates of complex vascular reconstruction and eventual amputation. Limb loss was not predicted by arterial ligation in one- and two-vessel injuries, suggesting that selective reconstruction in these cases is advisable.

PO-02-056 REAL-TIME VIDEO ASSISTED THORACOSCOPIC SURGERY IN HIGH-RISK TRANSVENOUS LEAD EXTRACTION

Laceration injury to the superior vena cava (SVC) remains the most feared complication of transvenous lead extraction (TLE). Early recognition is crucial to prevent catastrophic complications. Use of real time video assisted thoracoscopic surgery (VATS) during high risk TLE can potentially be useful for prompt recognition of SVC injury. We describe the use of video assisted thorascopic surgery (VATS) guidance for complex transvenous lead extractions (TLE). We conducted a retrospective analysis of all patients that underwent TLE at our institution from September 2018 to November 2022. Our TLE protocol uses a risk stratification scheme of level 1, 2 and 3 based on perceived risk. Defibrillation leads with a dwell time of >10 years or presence of 3 leads with oldest lead >10 years qualify as level 3 TLE cases. All procedures are performed with surgical back up with the use of VAT via a right thoracoscopic approach in level 3 cases. During single lung ventilation, the surgeon places a camera port to provide visualization of the SVC and right atrium for direct visualization during the laser/mechanical sheath manipulation in the great vessels. Out of 41 patients that underwent TLE during the study period, 10 patients underwent concomitant right VATS. Mean age of cohort was 61.5 + 15.2 years and 70% were males. Mean BMI and LVEF was 28.8 + 7.9 & 28.5 + 5.9 % respectively. Indications for TLE included lead malfunction (50%), infection (40%) and removal of abandoned leads in 1 patient. Mean lead dwell time was 10.4 + 5.6 years. Laser sheath was used in all cases with 2 patients requiring use of additional mechanical sheaths. One case demonstrated externalized ICD coil and extraction was abandoned. A femoral approach with snaring was done in 1 patient. All patients had adequate visualization of the SVC via VATS during TLE. Average procedure duration was 134 + 79.1 minutes. There were no immediate procedural complications. VATS port was removed and a chest drain was placed which was removed on post operative day 1 in all patients. VATS allows for direct visualization of the venous structures, provides real time information regarding impending venous injury, and is feasible with minimal impact on procedural risk and length of stay.

Utility of balanced steady-state field precession sequence in the evaluation of retinal and subdural hemorrhages in patients with abusive head trauma.

Abusive head trauma is the leading cause of physical child abuse deaths in children under 5years of age in the United States. To evaluate suspected child abuse, radiologic studies are typically the first to identify hallmark findings of abusive head trauma including intracranial hemorrhage, cerebral edema, and ischemic injury. Prompt evaluation and diagnosis are necessary as findings may change rapidly. Current imaging recommendations include brain magnetic resonance imaging with the addition of a susceptibility weighted imaging (SWI) sequence which can detect additional findings that suggest abusive head trauma including cortical venous injury and retinal hemorrhages. However, SWI is limited due to blooming artifacts and artifacts from the adjacent skull vault or retroorbital fat, which can affect the evaluation of retinal, subdural, and subarachnoid hemorrhages. This work explores the utility of the high-resolution, heavily T2 weighted balanced steady-state field precession (bSSFP) sequence to identify and characterize retinal hemorrhage and cerebral cortical venous injury in children with abusive head trauma. The bSSFP sequence provides distinct anatomical images to improve the identification of retinal hemorrhage and cortical venous injury.

Utility of a multipurpose catheter for transvenous extraction of old broken leads: A novel technique for fragile leads

Transvenous lead extraction has been possible since the 1980s. However, complications during lead extraction, such as the distal end fragment of the lead remaining in the myocardium or venous system and injury to the veins or heart, have been reported. The purpose of this study was to examine our method for complete removal of a separated lead, as extraction of long-term implanted devices is difficult using standard methods and may require additional procedures. The removal of leads with inner conductor coil and lead tip separated from outer insulation, conductor coil, and proximal ring electrode using a multipurpose catheter is reported. In total, 345 consecutive patients who underwent transvenous lead extraction (TLE) from April 2014 to March 2021 were retrospectively analyzed. Lead characteristics, device type, and indications for extraction were further analyzed in 20 patients who developed separation of the proximal ring electrode and outer conductor coil from the inner conductor and distal tip at the time of extraction. Extractions were performed using an excimer laser sheath laser and a Byrd polypropylene telescoping sheath (n = 15); laser, Byrd polypropylene telescoping sheath, and Evolution RL (n = 2); laser and Evolution RL (n = 3); Byrd polypropylene telescoping sheath and Evolution RL (n = 1); Byrd polypropylene telescoping sheath only (n = 4); and Evolution RL only (n = 2). Twenty-seven leads implanted for more than 10 years had lead separation. A multipurpose catheter was used to protect the fragile leads from further damage. All leads were completely extracted. All distal tip-to-proximal ring electrode separated leads were successfully removed using laser and other sheaths with the assistance of a multipurpose catheter, without any part of the leads remaining in the heart.

Treatment of Venous Thromboembolism in Trauma Patients: Features and Possibilities

The aim. Treatment of venous thromboembolism continues to be one of the most controversial problems of modern angiology. This issue is especially relevant in the treatment of patients with traumatological pathology.&#x0D; Methods. Treatment of 1915 patients with fractures of lower extremities from 2017 to 2022 at the Vinnytsia Regional Pyrohov Clinical Hospital was analyzed. During the study period, 727 (38%) deep vein thromboses were diagnosed.&#x0D; Results. During the study period, 4 (0.2%) pulmonary embolisms were diagnosed, among which 3 (0.15%) were fatal.&#x0D; In 99.5% of patients with venous thrombosis and injuries, it was possible to achieve clinical improvement and regression of the thrombotic process.&#x0D; Conclusions. Treatment tactics for trauma patients with venous thromboembolism should be individualized and take into account the severity and localization of the injury, the need and urgency of trauma surgery, the risk of pulmonary embolism.

Outcomes following ipsilateral great saphenous vein bypass for lower extremity arterial injuries

ObjectiveUse of autologous great saphenous vein (GSV) grafts for repair of extremity arterial injuries is well established. Contralateral great saphenous vein (cGSV) is traditionally used in the setting of lower extremity vascular injury given the risk of occult ipsilateral superficial and deep venous injury. We evaluated outcomes of ipsilateral GSV (iGSV) bypass in patients with lower extremity vascular trauma. MethodsPatient records at an ACS verified Level I urban trauma center between 2001 and 2019 were retrospectively reviewed. Patients who sustained lower extremity arterial injuries managed with autologous GSV bypass were included. Propensity-matched analysis compared the iGSV and cGSV groups. Primary graft patency was assessed via Kaplan-Meier analysis at 1-year and 3-years following the index operation. ResultsA total of 76 patients underwent autologous GSV bypass for lower extremity vascular injuries. 61 cases (80%) were secondary to penetrating trauma, and 15 patients (20%) underwent repair with iGSV bypass. Arteries injured in the iGSV group included popliteal (33.3%), common femoral (6.7%), superficial femoral (33.3%), and tibial (26.7%), while those in the cGSV group included common femoral (3.3%), superficial femoral (54.1%), and popliteal (42.6%). Reasons for using iGSV included trauma to the contralateral leg (26.7%), relative accessibility (33.3%), and other/unknown (40%). On unadjusted analysis, iGSV patients had a higher rate of 1-year amputation than cGSV patients (20% vs. 4.9%), but this was not statistically significant (P = 0.09). Propensity matched analysis also found no significant difference in 1-year major amputation (8.3% vs. 4.8%, P = 0.99). Regarding ambulatory status, iGSV patients had similar rates of independent ambulation (33.3% vs. 38.1%), need for assistive devices (58.3% vs. 57.1%), and use of a wheelchair (8.3% vs. 4.8%) compared cGSV patients at subsequent follow-up (P = 0.90). Kaplan-Meier analysis of bypass grafts revealed comparable primary patency rates for iGSV versus cGSV bypasses at 1-year (84% vs. 91%) and 3-years post-intervention (83% vs. 90%, P = 0.364). ConclusionIpsilateral GSV may be used as a durable conduit for bypass in cases of lower extremity arterial trauma where use of contralateral GSV is not feasible, with comparable long-term primary graft patency rates and ambulatory status.

Anterior Abdominal Varicosities Due to Unilateral Common and External Iliac Vein Occlusion Five Decades Post-Injury.

Abdominopelvic varicosities are a rare occurrence after traumatic venous injuries. Several disorders exist that present with abdominopelvic varicosities such as May-Thurner syndrome, pelvic congestion syndrome, and nutcracker syndrome; however, it has rarely been described after trauma.1 We present a case in 70-year-old male, who in 1974 sustained a penetrating injury from fragments secondary to mortar explosion, requiring exploratory laparotomy. He presented to the hospital with abdominopelvic varicosities that began 20 years after the incident and was asymptomatic at initial presentation. While there is a known case report of congenital absence of a common iliac vein in a young, healthy, athletic man who developed abdominopelvic varicosities, this is the first case report, to our knowledge, of evolution of a traumatic injury of this nature over a lifetime. Pathophysiology, diagnostics, risks of ligation, and management of chronic abdominopelvic varicosities in this patient are discussed.