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Although randomized data remain inconclusive, invasive endovenous therapy is increasingly favored in patients with extensive iliocaval or iliofemoral deep vein thrombosis (DVT) to reduce the rates of postthrombotic syndrome. Previously, pharmacomechanical thrombectomy was the therapy of choice, but the Inari ClotTriever device is an appealing, purely mechanical, alternative. It may reduce bleeding risk, intensive care unit admission, and the need for multiple procedures when compared with traditional thrombolysis. We present a series of 18 patients treated with the ClotTriever for extensive iliocaval or iliofemoral DVT.The Inari ClotTriever is a percutaneous mechanical thrombectomy system consisting of an expandable nitinol collection bag that is dragged along the vein wall, separating and capturing thrombus for collection into the retrieval sheath. We retrospectively reviewed all patients undergoing ClotTriever thrombectomy since the device became available at our quaternary referral center in June 2019. The review of these patients' records was determined to be exempt by our institutional review board.Eighteen patients underwent ClotTriever thrombectomy between June 2019 and November 2021. Most patients (N = 16, 89%) presented within 2 weeks of symptom onset, and identifiable provoking factors were present in all patients. The most common provoking factor was anatomy, with May-Thurner syndrome present in 8 patients. All patients had restoration of unimpeded venous flow in the treated segments, although 3 had some residual nonflow limiting thrombus. There were no bleeding events or repeat venous procedures. The median postprocedure length of stay of 2 days. Postoperative venous imaging was performed in 15 patients and showed patency of the treated segment in 14 patients. Revised Clinical Venous Severity Scores were available in 14 patients during the course of follow-up. Of these, 9 patients' highest scores were 0, 2 patients' highest scores were 2, 2 patients' highest scores were 4, and 1 patient had a high score of 8.Venous flow was re-established in all 18 patients treated with the ClotTriever in this series, with no bleeding complications, and median postprocedure length of stay of 2 days. All patients with available follow-up, except 1, retained patency of the treated venous segments, and most had mild postthrombotic syndrome or none at all. These findings suggest that the ClotTriever is a safe and effective way to treat extensive iliocaval/femoral DVT.

Optimal management of concomitant coronary artery disease and carotid artery stenosis remains unknown. Current treatment strategies for patients with significant dual disease burden include simultaneous carotid endarterectomy and coronary artery bypass grafting (CABG) or staged carotid endarterectomy and CABG. Herein we present the case of a patient with severe coronary artery disease and carotid artery stenosis and discuss a novel hybrid approach to management of concomitant coronary and carotid disease using transcarotid artery revascularization with flow reversal before CABG. Keywords: Carotid artery stenosis, Transcarotid artery revascularization (TCAR), Combined coronary artery disease

The widespread adoption of endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAA) is due to the obvious advantages of the procedure compared to the traditional open repair. However, these advantages have to be weighed against the increased risk of renal dysfunction with EVAR. The evaluation of the perioperative renal function after EVAR has been hampered by the lack of sensitive and specific biochemical markers of acute kidney injury (AKI). The purpose of this study was to summarize all novel renal biomarkers and to evaluate their clinical utility for the assessment of the kidney function after EVAR. A systematic review of the current literature, as the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines, was performed to identify relevant studies with novel renal biomarkers and EVAR. Pubmed and Scopus databases were systemically searched. Studies reporting on thoracic endovascular aortic repair (TEVAR), case reports, case series, letters to the editor, and systematic reviews were excluded. Neutrophil-Gelatinase-Associated Lipocalin, Cystatin C, Liver-type fatty-acid-binding protein were the most common among the eligible studies while Interleukin-18, Retinol binding protein, N-acetyle-b-D-glucosaminidase and microalbumin have a sparse appearance in the literature. These biomarkers have been assessed in plasma as well as urine samples with each sample material having its own advantages and drawbacks. Which of these biomarkers has the most potential for assessing postoperative renal failure after EVAR, remains to be proved. The few studies presented in the literature show the potential clinical utility of these biomarkers, but larger studies with longer follow-up are required to determine the precise relationship between these biomarkers and postoperative acute kidney injury.

Below-knee amputation remains the most common level of amputation in patients with lower extremity gangrene and critical limb ischemia. Failure to heal, requiring additional operative debridement or conversion to an above-knee amputation remains a significant cause of patient morbidity. There remains no definitive diagnostic test that can accurately predict healing of the amputation site. We report a case utilizing a hybrid technique of retrograde transamputation revascularization via balloon angioplasty. This proximal, retrograde approach allows for relatively easy crossing and treatment of the infrainguinal chronic total occlusions (CTOs), improving arterial inflow for optimal wound healing.

Objective: The management of patients with combined severe carotid artery and coronary artery disease (CAD) is controversial. Transcarotid stenting with flow reversal (TCAR) is a novel hybrid technique for carotid revascularization. We sought to investigate the safety and feasibility of simultaneous TCAR and coronary artery bypass grafting (CABG) for concomitant carotid and CAD. Methods: A single-institution, retrospective study of patients with critical carotid artery stenosis and symptomatic CAD who underwent simultaneous TCAR-CABG was completed. The primary outcomes were technical success, perioperative stroke, death, and hemorrhage. Results: Four patients underwent TCAR-CABG. All patients were male with a mean age of 64. Technical success was achieved in all cases. There were no perioperative strokes or deaths. There were no reexplorations for hemorrhage. Conclusions: Transcarotid stenting with flow reversal-CABG is a technically feasible hybrid approach for simultaneous carotid and coronary revascularization. It should be part of the vascular surgeon’s armamentarium for coexisting carotid and coronary disease. Further research focused on patient selection and perioperative antiplatelet management is warranted prior to the widespread adoption of this technique.

Femoral arterial cannulation in adult venoarterial (VA) extracorporeal membrane oxygenation (ECMO) predisposes patients to ipsilateral limb ischemia. Placement of a distal perfusion catheter (DPC) is one of few techniques available to prevent or manage this complication. Although frequently used, the indications for and timing of DPC placement are poorly characterized, and no guidelines are available to guide its use. The purpose of this study was to compare the incidences of vascular complications and limb ischemia between patients who did and did not receive a DPC at the time of primary ECMO cannulation. Between June 2009 and April 2015, 132 adults underwent VA ECMO cannulation at our institution. Of the 80 femoral cannulations comprising this retrospective single-center study cohort, 14 (17.5%) received a DPC at the time of primary cannulation. Demographics, indications for ECMO, and cardiovascular history and risk factors were not significantly different between comparison groups. Median arterial cannula size was 17 French in both groups. Vascular complications occurred in 2 of the 14 patients with initial DPC (14.3%) compared with 21 of 66 without initial DPC (31.8%; p = 0.188). Limb ischemia occurred in 2 of 14 patients in the DPC group (14.3%) and 15 of 66 in the non-DPC group (22.7%; p = 0.483). In-hospital mortality was comparable between groups. DPC placement at the time of primary cannulation may lower the incidence of limb ischemia. The benefit of DPC placement once evidence of limb ischemia is apparent remains unclear.

Objective Transcarotid artery revascularization (TCAR) is a hybrid technique for carotid artery revascularization that relies on proximal carotid occlusion with flow reversal for distal embolic protection. The hemodynamic response of the intracranial circulation to flow reversal is unknown. In addition, the rate and pattern of cerebral embolization during flow reversal has yet to be investigated. The aim of this study was to characterize cerebral hemodynamic and embolization patterns during TCAR. Methods A single-institution retrospective study of patients with carotid artery stenosis undergoing TCAR with intraoperative transcranial Doppler (TCD) monitoring of the middle cerebral artery (MCA) was performed. Primary outcomes included changes in MCA velocity and MCA embolic signals observed throughout TCAR. Results Eleven patients underwent TCAR with TCD monitoring of the ipsilateral MCA. The average MCA velocity at baseline was 50.6 ± 16.4 cm/s. MCA flow decreased significantly upon initiation of flow reversal (50.5 ± 16.4 cm/s vs 19.1 ± 18.4 cm/s; P = .02). The reinitiation of antegrade flow resulted in a significant increase in the number of embolic events compared with baseline (P = .003), and embolic events were observed in two patients during flow reversal. Conclusions TCD monitoring of patients undergoing TCAR revealed that the initiation of flow reversal results in a decrement in ipsilateral MCA velocity. Furthermore, embolic events can occur during flow reversal and are significantly associated with the reinitiation of antegrade flow in the internal carotid artery. However, both of these hemodynamic events were well-tolerated in our cohort. These findings suggest that TCAR remains a safe neuroprotective strategy for carotid revascularization.

Background Many patients with peripheral vascular disease (PAD) requiring revascularization do not have adequate ipsilateral great saphenous vein (GSV) for constructing a bypass because of intrinsic vein disease or prior harvesting for limb or coronary bypass. Prosthetic conduits have poor long-term patency, especially for distal bypass. With advancing endovascular sophistication, tibial angioplasty may be a good revascularization option, but we hypothesize that using spliced arm vein for distal lower extremity bypass is still a well-tolerated and more durable solution. Methods A retrospective chart review was conducted of all PAD patients undergoing lower extremity bypass or tibial angioplasty for lifestyle-limiting claudication or critical limb ischemia at a single institution over a 7-year period. Statistical analysis was conducted by Kaplan–Meier survival analysis and Cox proportional hazards model. Statistical significance was set at P = 0.05. Results From 2005 to 2012, there were 120 patients who underwent infrageniculate revascularization with conduit other than GSV. Over half of the patients (66 patients, 71.2% male, mean age 62 years) underwent bypass operations using arm vein conduit, and 88% of those bypasses were to tibial vessels. Patency was 100% at 1 year and 85% at 2 years. There was no impact on patency or amputation rate based on the source of vein or the number of splices. Forty-three patients underwent tibial angioplasty and patency was 70% at 1 year and 50% at 2 years. Conclusions When GSV is not available, spliced arm vein grafts provide durable lower extremity revascularization with favorable patency and limb preservation rates. Spliced arm vein grafts should be considered over prosthetic grafts and angioplasty alone in patients with distal occlusive disease.

Background Although the need for intraoperative shunting during carotid endarterectomy (CEA) is intensely debated, relatively few studies have compared the neurologic outcomes of patients undergoing CEA with or without shunts. The objective of our analysis was to determine the impact of intraoperative shunting during CEA on the incidence of postoperative stroke. Methods The 2012 CEA-targeted American College of Surgeons National Surgical Quality Improvement Program database was used for this analysis. The preoperative and operative characteristics of patients undergoing CEA with or without intraoperative shunting were compared. From this overall sample, propensity score techniques were then used to match patients with or without intraoperative shunting for a number of variables, including age, degree of ipsilateral and contralateral carotid stenosis, presence of several anatomic or physiologic risk factors, anesthesia modality, and use of patch angioplasty vs primary arteriotomy closure. The 30-day postoperative mortality and combined stroke/transient ischemic attack (TIA) rates of this matched cohort were then compared. A similar analysis was also performed on a subgroup of patients with severe stenosis or occlusion of the contralateral carotid artery. Results A total of 3153 patients were included for initial analysis (2023 "no-shunt" patients vs 1130 "shunt" patients). From this overall sample, propensity score matching yielded a cohort of 1072 patients with or without intraoperative shunt placement who were well matched for all known patient- and procedure-related factors. There was no significant difference in the incidence of postoperative stroke/TIA between the two groups of this matched cohort (3.4% in the no-shunt group vs 3.7% in the shunt group; P = .64). Analysis of a similarly well matched subgroup of patients with severe stenosis or occlusion of the contralateral carotid artery demonstrated a statistically nonsignificant increase in the incidence of postoperative stroke/TIA with the use of intraoperative shunting (4.9% in the no-shunt group vs 9.8% in the shunt group; P = .08). Conclusions There is no clinical benefit to intraoperative shunting during CEA, even in patients who may be at high risk for intraoperative cerebral hypoperfusion due to severe stenosis or occlusion of the contralateral carotid artery.

Endovascular approaches have replaced open surgical revascularization in most patients with mesenteric ischemia; however, flush ostial occlusions may not be amenable to traditional antegrade access. Retrograde mesenteric stenting has been previously described, but this technique requires a formal laparotomy and dissection of the proximal superior mesenteric artery. We present here a modification of this technique that requires only a "mini-laparotomy" and no open vascular repair of the superior mesenteric artery as well as a review of our initial institutional experience with this procedure. Our approach differs from previously described work by minimizing mesenteric dissection, avoiding the need for repair of an arteriotomy, and limiting the size of the laparotomy incision in this population of profoundly comorbid patients.

ObjectiveThe objective of this study was to describe the outcomes of surgical revascularization for lower extremity arterial thromboembolism in patients with advanced malignancy.MethodsThe 2005-2011 American College of Surgeons National Surgical Quality Improvement Program database was used for this study. Preoperative characteristics and postoperative outcomes of patients with known advanced malignancy who underwent surgical revascularization for lower extremity arterial thromboembolic disease were assessed and compared with those of patients without known advanced malignancy. Parsimonious multivariate logistic regression analysis was used to determine the independent association between advanced malignancy and 30-day postoperative mortality and morbidity after adjustment for demographic characteristics, acute and chronic comorbid disease burden, history of peripheral arterial disease, functional and nutritional status, acuity of presentation, and procedure type.ResultsThe study included 136 patients with advanced malignancy who underwent surgical revascularization for lower extremity arterial thromboembolism for analysis (65% thromboembolectomy, 26% thromboendarterectomy, and 22% bypass grafting). The 30-day mortality and morbidity rates in these patients were 30.2% and 38.2%, respectively. Compared with patients without advanced malignancy, patients with advanced malignancy had a significantly greater risk of postoperative death (adjusted odds ratio, 5.92; 95% confidence interval, 3.69-9.52; P < .001) but not morbidity (adjusted odds ratio, 1.28; 95% confidence interval, 0.87-1.87; P = .21).ConclusionsOur study is the largest to date to describe the outcomes of patients with advanced malignancy who undergo surgical revascularization for arterial thromboembolism of the lower extremities. Such patients suffer high rates of early postoperative mortality and morbidity, especially when emergency operation is required. Early involvement of palliative care specialists is warranted in these patients to ensure that the decision to pursue surgical revascularization is aligned with their goals of care.

Background Aortic thrombus in the absence of atherosclerotic plaque or aneurysm is rare, and its optimal management remains unclear. Although atypical aortic thrombus (AAT) has been historically managed operatively, successful nonoperative strategies have been recently reported. Here, we report our experience in treating patients with AAT that has evolved from a primarily operative approach to a first-line, nonoperative strategy. Methods Records of patients treated for AAT between 2008 and 2011 at our institution were reviewed. Results Ten female and three male patients with ages ranging from 27 to 69 were identified. Seven were treated operatively and 6 nonoperatively. Initial presentation was variable and included limb thromboembolic events ( n = 6), visceral ischemia ( n = 5), and stroke ( n = 1). Associated risk factors included hypercoagulability (76%; n = 10) and hyperlipidemia (38%, n = 5). In the nonoperative group, complete thrombus resolution was obtained via anticoagulation ( n = 5) or systemic thrombolysis ( n = 1). Complete thrombus extraction was achieved in all operative patients. There were 11 significant complications in 5 of the 7 patients (71%) in the operative group, including intraoperative lower extremity embolism, pericardial effusion, stroke, and 1 death. There was 1 complication in the patients treated nonoperatively. The median hospital length of stay was 9 days (range 3–49) for those treated nonoperatively and 30 days (range 4–115) for those undergoing operative thrombectomy. Conclusions Although AAT has traditionally been treated operatively, nonoperative management of AAT with anticoagulation or thrombolysis is feasible in selected patients and may lessen morbidity and length of hospitalization in those patients for whom it is appropriate.

There are very few data currently published on risk factors for early failure of lower extremity amputation procedures.All patients from the 2005-2010 American College of Surgeons NSQIP database who underwent isolated lower extremity amputation were included for analysis (excluding patients with earlier operation within 30 days, patients undergoing an open amputation, and patients undergoing another procedure during amputation). Multivariate logistic regression was used to determine predictors of early amputation failure (defined as need for reoperation within 30 days postoperatively) after adjustment for a number of preoperative and intraoperative variables.A total of 8,878 patients were included for analysis (4,258 below-knee amputations [BKA]; 3,415 above-knee amputations; and 1,205 transmetatarsal amputations). Overall rate of early amputation failure was 12.7% (12.6% for BKA, 8.1% for above-knee amputations, and 26.4% for transmetatarsal amputations; p0.0001). Several pre- and intraoperative variables appeared to be independently associated with early amputation failure, including emergency operation, transmetatarsal amputation (reference = BKA), sepsis (reference = no sepsis), septic shock (reference = no sepsis), end-stage renal disease, systemic inflammatory response syndrome (reference = no sepsis), intraoperative surgical trainee participation, body mass index ≥30, and ongoing tobacco use. Characteristics associated with decreased early amputation failure include age 80 years or older (reference = younger than 65 years), locoregional anesthesia, above-knee amputation (reference = BKA), operative time 40 to 59 minutes (reference =40 minutes), operative time ≥80 minutes (reference =40 minutes), and operative time 60 to 79 minutes (reference =40 minutes).Increased operative time and heightened supervision of participating surgical trainees can decrease the risk of early amputation failure. In addition, specific clinical situations, such as sepsis or emergency procedures, should prompt vascular surgeons to consider either an open amputation procedure or a more proximal closed amputation.

Malposition, embolization, fracture, and migration of endovascular devices are unfortunate consequences of endovascular intervention and will be encountered at some point by nearly every practitioner. The existing literature on foreign body retrieval consists of large single-institution series and case reports. We provide an overview of this recent literature, clarifying what devices are being lost, what symptoms occur as a result, and how retrieval is being performed. We have identified all case series and case reports since the year 2000, summarized the results, and made some general observations and recommendations that may be useful to the practitioner faced with the prospect of retrieving a fractured medical device, malpositioned coil, or migrated inferior vena cava filter.

BACKGROUND AND PURPOSE: Cervical MR imaging has demonstrated a utility for detecting soft tissue injury in nonaccidental trauma. The purpose of this study was to identify the incidence and types of cervical spine injury on MR imaging in nonaccidental trauma and to correlate cervical spine injury with parenchymal injury on brain MR imaging and findings on head CT. MATERIALS AND METHODS: A retrospective review of children diagnosed with nonaccidental trauma in a tertiary referral pediatric hospital over 8 years was performed. Inclusion criteria were children younger than 5 years of age, a confirmed diagnosis of nonaccidental trauma, and cervical spine MR imaging within 1 week of presentation. Brain and cervical spine MR imaging, head CT, cervical radiographs, and skeletal surveys were reviewed. RESULTS: There were 89 patients included in this study (48 males; mean age, 9.1 months [range, 1–59 months]). Cervical spine injury on MR imaging was found in 61 patients (69%). Ligamentous injury was seen in 60 patients (67%), with interspinous ligaments being most commonly involved. Abnormal capsular fluid (atlanto-occipital and atlantoaxial) was present in 28 patients (32%). Cervical spine injury on MR imaging was significantly associated with parenchymal restricted diffusion on brain MR imaging and parenchymal injury on head CT (P = .0004 and P = .0104, respectively). Children with restricted diffusion on brain MR imaging were 6.22 (point estimate) times more likely to have cervical spine injury on MR imaging. CONCLUSIONS: There is a high incidence of cervical spine injury in pediatric nonaccidental trauma. Positive findings may affect management and suggest a traumatic etiology.

Objective Subset analyses from small case series suggest patients requiring laparotomy during endovascular repair of ruptured abdominal aortic aneurysms (REVAR) have worse survival than those undergoing REVAR without laparotomy. Most concomitant laparotomies are performed for abdominal compartment syndrome. This study used data from the American College of Surgeons National Surgical Quality Improvement Program to determine whether the need for laparotomy during REVAR is associated with increased mortality. Methods Data were obtained from the 2005 to 2013 National Surgical Quality Improvement Program participant user files based on Current Procedural Terminology (American Medical Association, Chicago, Ill) and International Classification of Diseases-9 Edition coding. Patient and procedure-related characteristics and 30-day postoperative outcomes were compared using Pearson χ 2 tests for categoric variables and Wilcoxon rank sum tests for continuous variables. A backward-stepwise multivariable logistic regression model was used to identify patient- and procedure-related factors associated with increased death after REVAR. Results We identified 1241 patients who underwent REVAR, and 91 (7.3%) required concomitant laparotomy. The 30-day mortality was 60% in the laparotomy group and 21% in the standard REVAR group ( P P P Conclusions Laparotomy during REVAR is a commonly used technique for the management of elevated intra-abdominal pressure and abdominal compartment syndrome development. The results of this study strongly confirm findings from smaller studies that the need for laparotomy during REVAR is associated with significantly worse 30-day survival.

The diagnosis and treatment of venous thromboembolic events represents a significant source of medical spending, both domestically and worldwide. Advances in medical imaging and pharmacology continue to alter and improve established treatment paradigms. In this article, we discuss venous thromboembolism etiology, diagnosis, and rationale for current and future treatment strategies.

Background Although the overall incidence of venous thromboembolism (VTE) after open aortic surgery is low, it is not known whether specific factors can place patients at increased risk for this complication. The goal of our study was to identify patient and procedure characteristics that are associated with increased VTE risk after aortic surgery and that might therefore merit aggressive prophylaxis against this complication. Study Design All patients in the National Surgical Quality Improvement Program 2005−2009 Participant Use Data Files who underwent open aortic surgery for aneurysmal disease were included for analysis. Forward stepwise multivariate logistic regression analysis was used to identify patient and procedure characteristics associated with an increased risk of postoperative VTE events. Separate multivariate models were also used to predict which of 18 non-VTE postoperative complications might also be associated with an increased incidence of subsequent VTE, with adjustment for multiple comparisons. Results Postoperative VTE developed in 147 of 6,035 patients (2.4%) and in 60.5%, this complication developed after a non-VTE complication. Nine perioperative variables were found to be significantly associated with subsequent VTE on multivariate regression analysis. Patients with ≥3 of these risk factors were found to have a 3- to 4-fold higher incidence of postoperative VTE. Conclusions Our analysis identifies a group of patients who are at increased risk of postoperative VTE complications developing after open aortic surgery. Aggressive postoperative chemical or mechanical prophylaxis should be considered in these patients when appropriate.

This study was conducted to determine the potential effect of surgical trainee participation during infrainguinal bypass procedures on postoperative graft patency rates.Data from the National Surgical Quality Improvement Program (NSQIP) Participant User Files from 2005 through 2009 were retrospectively reviewed, using propensity score matching, to identify all patients undergoing infrainguinal bypass grafting procedures, excluding those who had prior operation ≤30 days of the index procedure. A separate analysis was performed on a subset of procedures from the entire NSQIP sample that was matched on propensity for intraoperative surgical trainee participation. The primary predictor variable was intraoperative surgical trainee participation. The main outcome measure was the 30-day postoperative graft failure rate.For the entire sample of 14,723 NSQIP patients undergoing infrainguinal bypass grafting, 30-day graft failure rates were significantly higher when a surgical trainee participated (5.8%) vs without participation (3.9%; P.0001). For the cohort of 9234 patients matched on their propensity for intraoperative trainee participation, this difference in graft failure rate remained significant (5.0% with participation vs 4.0% without participation; P = .02).Surgical trainee participation is an independent risk factor for technical failure after infrainguinal bypass grafting. Prospective evaluation is needed to determine the cause of this increase in graft failure rates for procedures that involve surgical trainees.

Blunt or penetrating trauma to the major arteries of the neck are challenging problems, however, newer diagnostic and therapeutic modalities have simplified care and largely eliminated the need for diagnostic neck exploration. High-quality computed tomographic angiography is quick and sensitive, identifying the vast majority of injuries prior to any operative intervention. Even in cases where active exsanguination or impending airway compromise mandates immediate exploration, intraoperative imaging and endovascular interventions have largely supplanted relatively morbid exposures for open repair. Traditional open repair of carotid injuries with primary closure or interposition grafting is effective over the long term and is always recommended if proximal and distal control can be achieved in a safe and straightforward manner. Endovascular repair of the proximal carotid, proximal subclavian, and distal internal carotid arteries is increasingly accepted. However, vertebral trauma is dealt with almost exclusively by endovascular means. Recent military experiences in Iraq and Afghanistan highlight the imaging-intensive management of cervical vascular trauma and demonstrate the effectiveness of computed tomography angiography, selective arteriography, and endovascular interventions.

Selective tibial revascularization refers to the practice of vessel repair vs ligation or observation based on factors observed at the time of injury. Although commonly employed, the effectiveness of this strategy and its impact on sustained limb salvage is unknown. The objective of this study is to define the factors most relevant in selective tibial artery revascularization and to characterize limb salvage following tibial-level vascular injury.The cohort of active-duty military patients undergoing infrapopliteal artery repair comprises the tibial Bypass group. A similarly injured cohort of patients that did not undergo operative vascular intervention (No Bypass group) was identified. All tibial vessel injuries were documented by angiography. Data were compiled via medical records and patient interview. The primary outcome measure was failure of limb salvage. Multivariate regression was performed to identify factors associated with revascularization and to describe factors associated with amputation.Between March 2003 and September 2008, 135 of 1332 patients with battle-related vascular injuries had documented tibial vessel disruption or occlusion. Of these, 104 were included for analysis. Twenty-one underwent autologous vein bypass at the time of injury (Bypass group), and the remaining 83 patients were managed without revascularization (No Bypass group). Mean follow-up (39 vs 41 months; P = .27), age (25 vs 27 years; P = .66), and mechanism of injury (88% vs 92% penetrating blast; P = .56) were similar, but the No Bypass group had higher Injury Severity Scores (ISS; 16.3 vs 11.7; P.01). Injury characteristics, including Gustilo III classification (49% vs 43%; P = .81) and nerve injury (55% vs 53%; P = 1.0), were similar. Subjects were more likely to receive tibial bypass with an increasing number of tibial vessel occlusions and documented ischemia on initial exam. However, of the 23 in the No Bypass group with initially unobtainable Doppler signals, 17 (74%) regained pedal flow following resuscitation and limb stabilization. Amputation rates were similar (23% vs 19%; P = .79), but the prevalence of chronic limb pain was lower in the Bypass group (10% vs 30%, respectively; P = .08). Cox regression analysis of amputation-free survival demonstrated an association between mangled extremity severity score5 (hazard ratio [HR], 2.7; P = .01) and amputation.This report provides outcomes data for wartime tibial vascular injury, which supports a selective approach to tibial artery revascularization. Clinical factors such as ISS and degree of ischemia guide which patients are best suited for tibial vascular repair, while injury-specific characteristics are associated with amputation regardless of revascularization status.

Artifacts produced by metallic fragments and orthopedic hardware limit the usefulness of conventional computed tomography in many military trauma patients. Contemporary literature suggests that multidetector computed tomographic angiography (MDCTA) by resolving these limitations may provide a useful noninvasive alternative to invasive arteriography. The objective of this study is to review the utility of MDCTA in the evaluation of recent combat casualties with vascular injuries.Data on all vascular trauma patients seen by our service has been collected prospectively and entered into a database. A retrospective review was conducted of patients seen from August through December 2006 who underwent MDCTA. Patient demographics, mechanism of injury, modality of evaluation, and findings were recorded.Twenty patients underwent MDCTA. Thirteen patients were injured by blast fragments. Seven patients were injured by gunshot wounds. Nineteen of 20 studies were diagnostic and one was judged to be indeterminate. Studies in nine patients identified arterial injuries. Multiple extremities were evaluated with a single study in 16 patients. Fifteen studies assessed the lower extremities, four the upper extremities and two the neck. Fourteen patients in this series had retained fragments, 10 had external fixators or intramedullary rods, and only 4 had neither retained fragments nor orthopedic hardware. MDCTA allowed for assessment of the arterial runoff despite hardware or fragments in 15 of 16 (94%) patients. Comparative studies were available in four patients in addition to MDCTA. There were no missed injuries in these four patients.MDCTA yielded high resolution images that were very useful for the delayed evaluation of combat casualties. The presence of metallic fragments or orthopedic hardware did not significantly interfere with MDCTA. It is a reliable and promising alternative to traditional arteriography for evaluating clinically occult vascular trauma.

Background: High velocity fragments have resulted in a multitude of complex injuries in the military patients, placing them at increased risk of venous thromboembolism. Methods: A retrospective analysis was performed of all the intravascular ultrasound (IVUS)-guided bedside inferior vena cava (IVC) filters placed between August 2003 and October 2007. Results: Fourteen patients had bedside IVUS-guided retrievable filter placement. Thirteen males and one female and the mean (+SD) injury severity scores (ISS) was 37.2 (+9.9). The most common causes of injury were explosive devices (57%), gunshot wounds (28%), rocket-propelled grenades (7%), and motor vehicle crashes (7%). Indications for filter insertion were deep venous thrombosis in 36% of patients and pulmonary embolus in 28%. Thirty five percent had filters inserted prophylactically. Conclusions: Military trauma population ISS is considerably higher than what is reported in the civilian population. The bedside IVUS-guided IVC filter insertion is particularly useful in this population.

Background: The use of prosthetic grafts for reconstruction of military vascular trauma has been consistently discouraged. In the current conflict, however, the signature wound involves multiple extremities with significant loss of soft tissue and potential autogenous venous conduits. We reviewed the experience with the use of prosthetic grafts for the treatment of vascular injuries sustained during recent conflicts in Iraq and Afghanistan. Methods: Trauma registry records with combat-related vascular injuries repaired using prosthetic grafts were retrospectively reviewed from March 2003 to April 2006. Data collected included age, gender, mechanism of injury, vessel injured, conduit, graft patency, complications, including amputation and eventual outcome of repair. Results: Prosthetic grafts were placed in 14 of 95 (15%) patients undergoing extremity bypass for vascular injuries. Patients were men with an average age of 25 years (range, 19–39 years). All prosthetic grafts in this series were made of polytetrafluoroethylene. Mechanism of injury included blast (n = 6), gunshot wounds (n = 6), and blunt trauma (n = 2), resulting in prosthetic repair of injuries to the superficial femoral (n = 8), brachial (n = 3), common carotid (n = 1), subclavian (n = 1), and axillary (n = 1) arteries. Mean evacuation time from injury to stateside arrival was 7 days (range, 3–9 days). Twelve grafts were placed initially at the time of injury, and two after vein graft blow out with secondary hemorrhage. The mean follow-up period was 427 days (range, 49–1,285 days). Seventy-nine percent of prosthetic grafts stayed patent in the short term, allowing patient stabilization, transport to a stateside facility, and elective revascularization with the remaining autologous vein graft. Three prosthetic grafts were replaced urgently for thrombosis. The remaining seven grafts were replaced electively for severe stenosis (3) or exposure (4) with presumed infection. There were no prosthetic graft blow outs or deaths in this series. No patients required amputation because of prosthetic graft failure. Three (21%) patients went on to have elective lower extremity amputation, despite patent grafts for nonsalvagable limbs. Conclusions: When managing patients with multiple extremity trauma and limited noninjured autogenous venous conduits, emergent use of prosthetic grafts may provide an effective limb salvage strategy. Despite being placed in multisystem trauma patients with large contaminated soft tissue wounds, emergent revascularization with polytetrafluoroethylene allowed patient stabilization, transport to a higher echelon of care, and elective revascularization with remaining limited autologous vein.

Endovascular techniques are widespread in the management of civilian trauma and provide standard treatment for select injuries. Despite the commonality of this less invasive technology, there have been no reports on its use in wartime. The objective of this study was to describe the implementation of endovascular capability at a level III surgical facility in Iraq and illustrate the effectiveness of catheter-based techniques.From September 1, 2004 through April 30, 2007, injuries at the Air Force Theater Hospital, Balad, Iraq, were registered in a database and reviewed. Patients in whom endovascular procedures were performed comprise the study group (N = 139).During this period, 150 catheter-based procedures were performed, including placement of 39 vena cava filters. The 111 nonfilter procedures were performed in the setting of extremity (N = 72), cervical (N = 19), and torso (N = 20) injuries. Of the diagnostic procedures, an abnormal finding was present in 67 (61%) cases, and 47 of these underwent either open surgical repair (N = 30) or endovascular treatment (N = 17). Endovascular therapies fell into three categories: embolization (N = 10), covered stent placement (N = 5), or miscellaneous (N = 2). The technical success rate of endovascular treatments was 100%, and procedure-related complications were uncommon (N = 4; 3%).This report is the first to demonstrate the effectiveness of diagnostic and therapeutic endovascular capability in the management of acute wartime injury. Implementation of this capability has unique requirements related to imaging and a trauma-specific endovascular inventory. Once established, however, endovascular capability markedly expands the injury management armamentarium and, in certain cases, provides the preferred treatment.

Recent combat casualties have stimulated a reassessment of the principles of management of high-risk extremity injuries with a normal vascular examination. Rapid evacuations have presented numerous U.S. soldiers to our service for evaluation in the early postinjury period. The objective of this single-institution report is to analyze the application of liberal arteriography in the delayed evaluation of modern wartime extremity injuries. Data from consecutive wartime evacuees evaluated for extremity injuries between March 2002 and November 2004 were prospectively entered into a database and retrospectively reviewed. Analysis was focused on arteriography and its role in our current diagnostic and therapeutic approach. Information including injury sites and mechanisms, associated trauma, battlefield repairs performed, arteriography technique, complications, findings, and need for further intervention were reviewed. Indications for imaging in this high-risk group included proximity to vascular structures, abnormal or equivocal physical examination, adjunctive operative planning, and evaluation of battlefield repair. Ninety-nine of 179 patients (55%) with extremity injuries underwent arteriography, with 142 total limbs studied. The majority of them were wounded by explosive devices (82%) or high-velocity rifle munitions (14%). Abnormalities were found in 75 of 142 (52.8%) imaged limbs in 46 of the 99 (46.5%) patients. Twenty-four of these patients (52.2%) required additional operative intervention. Occult vascular injury findings were associated with bony fracture in 68% and nerve injury in 16%. Median delay between injury and stateside evaluation was 6 days. Two thirds of these soldiers presented with a normal physical examination result. There were no access site complications or incidents of contrast-induced acute renal failure. The liberal application of arteriography is a low-risk method to provide high-yield data in the delayed vascular evaluation of extremities injured from modern military munitions. Physical examination findings remain the most useful indicator, but a normal examination can be misleading and should not guide the decision for invasive imaging. Lesions are found and require further intervention at a higher rate than expected from the typical civilian trauma experience.

While there is some local variability in the use of inferior vena cava filters and there has been some evolution in the indications for filter placement over time, inferior vena cava filters remain a standard option for pulmonary embolism prophylaxis. Indications are clear in certain subpopulations of patients, particularly those with deep venous thrombosis and absolute contraindications to anticoagulation. There are, however, a variety of reported inferior vena cava filter complications in the short and long term, making retrieval of the filter desirable in most cases. Here, we present the case of a morbidly obese patient complaining of chronic abdominal pain after inferior vena cava filter placement and malposition of the filter with extensive protrusion outside the inferior vena cava. She underwent successful laparoscopic retrieval of her malpositioned inferior vena cava filters after failure of a conventional endovascular approach.

Traumatic hemorrhage and vascular injury management have been concerns for both civilian and military physicians. During the 20th century, advances in technique allowed surgeons to focus on vascular repair, restoration of perfusion, limb salvage, and life preservation. Military surgeons such as Makins, DeBakey, Hughes, Rich, and others made significant contributions to the field of surgery in general and vascular surgery in particular. Casualties from combat in Afghanistan and Iraq confront physicians and surgeons with devastating injuries. The current generation of providers is challenged with applying contemporary care while expanding upon the lessons taught by our predecessors. The objective of this report is to review the historical experience with managing military upper extremity arterial injuries and compare that experience with current management.

The management of venous trauma continues to be debated. Historically, ligation of injured veins is the most common modality of surgical treatment. In the past half-century, additional techniques have been used, including primary repair, interposition graft, and occasionally endovascular techniques. Venous repair, whether in the acute or chronic setting, is believed to prevent or ameliorate the complications of pain, edema, and phlegmasia. Venous repair in civilian trauma and in wartime is commonplace; however, overall treatment strategies remain largely unchanged since the Vietnam War.

Background The effects of hormone replacement therapy (HRT) on the vascular endothelium have been controversial. In this study, we determined the effects of HRT on endothelium-dependent relaxation in a porcine coronary artery model. Methods Coronary artery rings harvested from female swine were incubated as controls or with estrogen (10−9, 10−8, 10−7 g/L), progesterone (1 × 10−6, 1 × 10−5, 5 × 10−5 g/L), or a combination of the two (10−8g/L estrogen, 1 × 10−5g/L progesterone). After 24 h in tissue culture, the rings were tested on a myograph system to measure contraction and endothelium-dependent relaxation. Myograph analysis was performed with the thromboxane A2 analogue U46619 for contraction and bradykinin or sodium nitroprusside for relaxation. Nitric oxide synthase (eNOS) levels were determined by immunohistochemistry. Levels of superoxide anion in the progesterone or estrogen treated tissues were assessed by lucigenin-enhanced chemiluminescence analysis. Results In response to 10−7M bradykinin, porcine coronary artery rings treated with 1 × 10−6, 1 × 10−5 and 5 × 10−5 g/L of progesterone showed a significant reduction in endothelium-dependent vasorelaxation by 36%, 45%, and 68%, respectively, as compared to controls (P Conclusion This data suggests that the progesterone component of HRT has a detrimental influence on endothelium-dependent relaxation. This effect appears to be related to decreased eNOS levels, as well as increased consumption of NO by superoxide anion in the endothelium of tissues exposed to progesterone. Estrogen can block progesterone-induced endothelial dysfunction and superoxide anion production in the pig coronary artery model.

Carotid aneurysms are rare, accounting for less than 4% of all aneurysms, and repair of this entity comprises only 0.9% of all carotid procedures at major referral centers. Stroke is the most frequent complication and the possibility of rupture is only rarely considered. Rupture of a nontraumatic, uninfected carotid aneurysm is an exceedingly rare event, with only a handful of cases documented in the world literature, most of which presented as an acute, life-threatening emergency. This report documents the highly unusual circumstance of subacute presentation of a ruptured carotid aneurysm.

Management of blunt and penetrating trauma to the carotid and vertebral arteries has moved away from an approach focusing on operative exploration and repair to a more imaging-intensive strategy. Early CTA and a focused operative or endovascular approach can minimize the potential for missed injury and operative morbidity.

Purpose Cle aring the cervical spine in a multiply injured trauma patient is a dilemma because clinical examination for ligamentous instability cannot be performed, and the standard cervical spine series can miss isolated ligamentous injury. Static flexion/extension views are unsafe, as the obtunded patient has no protective reflexes and cannot complain of pain during the exam. This results in a need for prolonged spinal immobilization and its attendant complications. Dynamic fluoroscopy may be useful in the detection of otherwise occult injuries. Methods We performed a prospective study of a cervical spine clearance algorithm incorporating dynamic fluoroscopy with flexion/extension views. Inpatient records over a 3-year period were reviewed. Patient demographic data, results of cervical spine films and fluoroscopic exams, interventions based on positive results, and missed injuries were recorded. Results One hundred ten patients with normal spine plain films underwent dynamic fluoroscopy with flexion and extension views of the cervical spine. The average Glasgow Coma Score was 9.2 and the average revised Trauma Score was 9.5. Nine patients had evidence of cervical instability on exam. Six of these were deemed stable by the orthopedic or neurosurgical spine consultants, and these patients had their hard collars removed. One patient with positive findings had cervical immobilization with hard collar continued, a second had halo placement, and a third underwent spinal fusion for atlanto-occipital disassociation. No patients undergoing dynamic fluoroscopy were subsequently found to have missed cervical spine injury. Conclusions With our protocol, 3 patients had significant cervical instability that would have been missed without dynamic fluoroscopy. Given the significant medical and legal ramifications of missed cervical spine injury and the benefits of early removal of cervical collars, more widespread use of dynamic fluoroscopy of the cervical spine is warranted.

Chronic cerebrospinal insufficiency, venous thoracic outlet syndrome, and superior vena cava syndrome are disease processes that are considered pathology of the deep upper venous system. The incidence, pathophysiology, diagnosis, and management are discussed in this chapter.

Deep venous insufficiency may manifest as limb edema, chronic leg pain, stasis dermatitis, or ulceration, and the symptoms may be chronically disabling. Initial therapy is directed at ulcer healing and control of symptoms with wound care and compression. Once conservative measures have been instituted, the next step may be evaluation for any surgically correctable contributors to the symptomatology. Although valvular dysfunction and consequent venous reflux are a major cause of the venous hypertension that underlies the clinical manifestations of chronic venous insufficiency (CVI), recent studies suggest that iliac venous outflow obstruction plays a more important role in the pathogenesis of CVI than previously estimated. Any combination of superficial, perforator, and/or deep venous reflux can result in various stages of CVI, but when multiple segments of venous system are affected, the manifestations of CVI increase in severity. The combination of reflux and obstruction produces the highest levels of venous hypertension and the most severe clinical symptoms. This chapter discusses iliocaval vein obstructions and pelvic venous congestion.