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Introduction: Vascular injury during acetabular screw fixation is a life-threatening complication of total hip arthroplasty. This study uses three-dimensional computed tomography to (1) measure absolute distance from the external iliac artery (EIA) to the acetabulum, (2) determine available bone stock along the EIA path, and (3) create a novel acetabular vascular risk map., Methods: A retrospective radiographic study was conducted using three-dimensional CT. Placement of four 6.5-mm screws in a radial projection from the acetabulum toward the EIA was simulated. The initial screw (Sc1) was placed anteriorly at the center of the anterior labral sulcus. The terminal screw (Sc4) was placed such that any screw placed further posteriorly would not be in contact with the EIA. The shortest distance to the EIA (AD) and acetabular bone depth (BD) were measured., Results: Fifty patients (100 hips) were included with an average age of 61.9 ± 15.4 years and average body mass index (BMI) of 27.5 ± 5.3 kg/m 2 . The mean AD at Sc1 was 25.1 ± 2.3 mm (range: 15.4 to 34.9), increasing to 71.5 ± 7.8 mm (range: 21.0 to 144.9) at Sc4. Mean BD at Sc1 was 4.6 ± 0.8 mm (range: 1.4 to 32.0), increasing to 20.1 ± 5.5 mm (range: 2.1 to 36.3) at Sc4. On univariate analysis, male patients demonstrated greater AD and BD at all screw positions. Multiple linear regression revealed an inverse correlation between age and AD and a direct correlation between weight and AD ( P value <0.005)., Conclusion: This study identifies the tip of the cotyloid fossa as a reliable intra-articular landmark during total hip arthroplasty. Surgeons should remain wary of potential vascular injury during transacetabular screw fixation, particularly when operating on elderly, female patients., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Background: Reversing heparin when managing coronary artery perforation (CAP) during percutaneous coronary intervention (PCI) can provide hemostasis but may cause coronary thrombosis if a device is still present in a coronary artery., Aims: To assess the impact of heparin reversal while an intracoronary artery device is in place for CAP., Methods: This study analyzed CAP cases during PCI from January 2006 to October 2023. Patients were grouped according to implementing heparin reversal while an intracoronary artery device was in place. The safety outcome was coronary thrombosis after CAP. The efficacy outcomes were successful hemostasis and death from any cause., Results: CAP occurred in 368 of 22,368 cases (1.6%). Patients who had heparin reversal with a device in place comprised 211 (57%). Among these, coronary thrombosis occurred in 16 (7.6%). An activated clotting time (ACT) 〈150 seconds was significantly correlated with coronary thrombosis. Heparin reversal with a device in place was significantly associated with successful hemostasis (heparin reversal 91% vs. no heparin reversal 73%; adjusted odds ratio 2.78; 95% confidence interval 1.27-6.13; p = 0.011), but was not different for death from any cause (heparin reversal 4.3% vs. no heparin reversal 5.7%; adjusted odds ratio 0.97; 95% confidence interval 0.28-3.43; p = 0.964)., Conclusion: Heparin reversal with a device in place was associated with an increased risk of coronary thrombosis when ACT was less than 150 seconds. While it may not have a substantial association with a reduced risk of mortality, it offers an advantage in achieving successful hemostasis., (© 2024 Wiley Periodicals LLC.)

Case: We present the case of a 24-year-old woman who sustained a left midshaft clavicle fracture with acute subclavian artery compression, subclavian vein laceration, and complete brachial plexus palsy after a motor vehicle collision. The patient underwent urgent open reduction internal fixation of the clavicle and repair of the subclavian vein. Two years later, she underwent opponensplasty and flexor digitorum profundus tendon transfers. She regained satisfactory hand function, allowing her to return to full-duty work., Conclusion: Clavicle fractures with associated acute neurovascular and brachial plexus injuries are rare pathologies that result from high-energy trauma and should undergo urgent fixation., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C524)., (Copyright © 2025 by The Journal of Bone and Joint Surgery, Incorporated.)

Introduction: Blunt traumatic aortic injury (TAI) is a critical condition and a leading cause of mortality in trauma patients, often resulting from high-speed accidents. Thoracic endovascular aortic repair (TEVAR) has developed into the preferred therapeutic approach due to its minimally invasive nature and promising outcomes. This study evaluates the safety and efficacy of TEVAR for managing TAI over a 10-year period at a Level-1 trauma center., Methods: A retrospective analysis was conducted on 19 patients with acute TAI treated with TEVAR between 2012 and 2022 at the University Hospital Zurich. Data were collected from digital records and analyzed according to the Fillinger TEVAR reporting framework. Outcomes included technical success, perioperative complications, and long-term graft durability., Results: The cohort had a mean age of 39 years and included patients with severe polytrauma. Technical success was achieved in 95% of cases, with no intraoperative deaths or need for open surgical conversion. Perioperative complications were minimal, and the reintervention rate was 5.3%. This study evaluates 10 years of clinical experience managing TAI with TEVAR. Long-term follow-up, with a median duration of 29 months, revealed no graft-related complications or secondary interventions. Imaging confirmed sustained graft integrity, and clinical outcomes were favorable., Conclusion: TEVAR is a reliable and effective treatment for traumatic aortic injuries, offering excellent technical success rates and minimal perioperative and long-term complications. This study highlights TEVAR's advantages in managing polytrauma patients and its role as a minimally invasive alternative to open surgery. Additionally, the findings emphasize the need for comprehensive long-term follow-up protocols. Future research should aim to address challenges related to device durability and the integration of advanced imaging techniques to further enhance patient outcomes and broaden the applicability of TEVAR in trauma care., Competing Interests: Declarations. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Purpose: Our aim was to update evidence-based and consensus-based recommendations for the inhospital endovascular management of haemorrhage and vascular lesions in patients with multiple and/or severe injuries based on current evidence. This guideline topic is part of the 2022 update of the German Guideline on the Treatment of Patients with Multiple and/or Severe Injuries., Methods: MEDLINE and Embase were systematically searched to June 2021. Further literature reports were obtained from clinical experts. Randomised controlled trials, prospective cohort studies, and comparative registry studies were included if they compared endovascular interventions for bleeding control such as embolisation, stent or stent-graft placement, or balloon occlusion against control interventions in patients with polytrauma and/or severe injuries in the hospital setting. The diagnosis of pelvic haemorrhage was added post-hoc as an additional clinical question. We considered patient-relevant clinical outcomes such as mortality, bleeding control, haemodynamic stability, transfusion requirements, complications, and diagnostic test accuracy. Risk of bias was assessed using NICE 2012 checklists. The evidence was synthesised narratively, and expert consensus was used to develop recommendations and determine their strength., Results: Forty-three new studies were identified. Interventions covered were resuscitative endovascular balloon occlusion of the aorta (REBOA) (n = 20), thoracic endovascular aortic repair (TEVAR) (n = 9 studies), pelvic trauma (n = 6), endovascular aortic repair (EVAR) of abdominal aortic injuries (n = 3), maxillofacial and carotid artery injuries (n = 2), embolisation for abdominal organ injuries (n = 2), and diagnosis of pelvic haemorrhage (n = 1). Five recommendations were modified, and one additional recommendation was developed. All achieved strong consensus., Conclusion: The following key recommendations are made. Whole-body contrast-enhanced computed tomography should be used to detect bleeding and vascular injuries. Blunt thoracic and abdominal aortic injuries should be managed using TEVAR/EVAR. If possible, endovascular treatment should be delayed beyond 24 h after injury. Bleeding from parenchymatous abdominal organs should be controlled using transarterial catheter embolisation. Splenic injuries that require no immediate intervention can be managed with observation., Competing Interests: Declarations. Conflict of interest: R. Braunschweig has consulting relations with Philips. All other authors have no competing interests to declare. Ethical statement: Ethical approval was not required because the study used publicly accessible documents as evidence. Data sharing: A full version of the guideline and its methods/evidence report are available online at https://register.awmf.org/de/leitlinien/detail/187-023 ., (© 2025. The Author(s).)

Background: Delayed stent grafting for blunt thoracic aortic injuries (BTAIs) is current standard of care. However, given the heterogeneity of pseudoaneurysm presentations, it is currently unclear which severe BTAIs require more urgent intervention. We hypothesize that a Traumatic Aortic Disruption Index (TADI) calculation based on sagittal computed tomography angiography imaging measurements would correlate with urgency of stent grafting., Methods: All patients at a level-1 trauma center with BTAIs over a 12-year period were identified. A TADI score was then calculated using the length of pseudoaneurysm (L), maximum width of pseudoaneurysm (W), and normal adjacent aortic diameter (NA). Patient presentation, injury characteristics, timing of stent grafting, and outcomes were then evaluated., Results: Forty-two patients were diagnosed with BTAIs. Mean age was 37.6 years, with a median injury severity score (ISS) of 29. Overall mortality was 11.9%. TADI scores ranged from 3.6 to 158.6. Compared to patients with a TADI <28, patients with TADI >28 had similar median ISS scores (34 vs. 29, P = 0.16), and rates of both traumatic brain injury (TBI; 33.3% vs. 42.0%, P = 0.53) and nonaortic hemorrhage control procedures (44.4% vs. 33.3%, P = 0.3). TADI >28 patients had a lower initial mean systolic BP (98.5 vs. 121.9, P = 0.003), more severe hypotension (lowest systolic 77.0 vs. 91.2, P = 0.034), lower initial Glasgow Coma Scale (6 vs. 13, P = 0.039), higher mean admission lactate (4.6 vs. 3.3, P = 0.036), and higher overall mortality (23.8% vs. 0%, P = 0.048). Patients with TADI >28 received stent grafting at significantly shorter median time intervals from injury identification (median 4 hrs vs. 14 hrs, P = 0.001). Overall causes of mortality were aortic hemorrhage related (n = 3, 60%) and TBI (n = 2, 40%)., Conclusions: This simple-to-calculate index is independently correlated with mortality and urgency of stent grafting in blunt trauma patients with similar ISS. Patients with TADI scores >28 were more likely to undergo urgent stent grafting, thereby suggesting a trend in practice patterns with higher scores representing injuries that should be considered for expedited operative management. The TADI score should be validated in a larger sample of blunt trauma patients as an injury prioritization tool in the multisystem injured patient., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objectives: Inferior vena cava (IVC) penetration is a prevalent complication following the placement of conical filters. However, there is a paucity of studies examining the penetration in smaller IVC. The objective of this study was to assess the time of penetration, the incidence of serious complications associated with penetration, and the process of IVC wall repair in the smaller IVC following the placement of a conical filter., Methods: Twenty pigs were randomly assigned to 2 groups and received either Celect or Denali filters. Weekly follow-up imaging using computed tomography venography (CTV) of the IVC was conducted to monitor the position of the IVC filter struts until at least 1 strut was observed to be penetrating the vessel wall. At necropsy, a comprehensive gross and histological examination was performed on the IVC and adjacent anatomical structures in all animals., Results: The puncture and cavography procedures were successfully conducted on all animals, and no significant differences were found in the mean diameter of the IVC between the Celect and Denali groups (15.89 ± 1.27 mm vs. 16.39 ± 1.39 mm, P > 0.05). All filters were implanted without complications. CTV detected IVC penetration within 9 weeks, which was confirmed during necropsy. The Celect group had a significantly earlier time of IVC penetration compared to the Denali group (2.43 ± 0.52 weeks vs. 6.81 ± 1.32 weeks, P ＜ 0.001). No evidence of filter tilt, fracture, migration, caval thromboses, retroperitoneal bleeding, wall hematoma, tearing of the IVC wall, or peripheral tissue and organ damage was observed during the CTV and subsequent necropsy. Additionally, histological analysis showed that the Celect group had a lower percentage area of collagen fiber compared to the Denali group (33.92% vs. 49.04%, P ＜ 0.001). The fiber proliferation was positively correlated linearly with the indwelling time of filter (r = 0.97, P ＜ 0.001)., Conclusions: Penetration can occur within a relatively brief period following the placement of the conical filter into the smaller IVC. Nevertheless, no short-term severe complications were observed in connection with the penetration. The proliferation of fibers in the IVC wall exhibited a positive linear correlation with the duration of filter indwelling., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Arterial trauma of the axillary subclavian segment carries considerable morbidity and mortality risks. Surgical approaches are challenging given the hidden trajectory of these vessels, which has made the endovascular approach a valid and potentially better alternative for managing these injuries. We describe the incidence of relevant outcomes for patients with traumatic axillary and/or subclavian artery injury who underwent endovascular therapy at a tertiary care university hospital over a 15-year period in Cali, Colombia., Methods: We conducted an incidence study based on clinical records that included patients aged 15 years or older with traumatic axillary subclavian arterial injury treated with endovascular therapy between 2008 and 2022. Vascular injuries caused by intra-arterial dialysis catheter insertion (iatrogenic) were excluded. We described clinical and imaging characteristics upon admission, perioperative findings, and the incidence of complications and in-hospital mortality, with accompanying 95% confidence intervals (CIs)., Results: We included 32 patients, 93.8% of whom were male, with a median (interquartile range) age of 30 (21-42) years. The type of trauma was penetrating in 75% of patients (62.5% corresponding to gunshot wounds) and blunt in 25%. Upon admission, 12 patients (37.5%) exhibited hard signs of vascular injury, and 20 patients (62.5%) exhibited soft signs. Fourteen patients (47%) had an Injury Severity Score greater than 15, and 12 (37.5%) had hemodynamic instability. All but 3 patients (90.6%) suffered subclavian artery injury (right 48.3%, left 51.7%), while 12.9% had axillary artery injury (one patient with both vessels affected). Intraoperative complications happened in one patient (3.1%, 95% CI: 0.2-18%). Pseudoaneurysms were identified in 11 patients (34.4%), thrombosis in 6 (18.8%), and dissection in 6 (18.8%). Three (9.4%) patients required hybrid management (endovascular therapy following conventional surgery). No cases of ischemia or amputation occurred. The length of hospital stay was 6 (3, 11.5) days. No cases of in-hospital mortality were reported (0%, 95% CI: 0.0-13.4%)., Conclusions: Endovascular treatment in trauma is a minimally invasive technique with favorable clinical outcomes in patients with arterial trauma in the axillary-subclavian segment. This should be a viable therapeutic option for selected cases., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Blunt thoracic aortic injuries (BTAIs) are traditionally treated as emergencies with most fixed within 24 hours of arrival by thoracic endovascular aortic repair (TEVAR) regardless of grade of injury. However, the optimal timing of repair remains debated., Methods: All patients with Grade 2 and 3 BTAI enrolled in the Aortic Trauma Foundation prospective multicenter registry from 2015 to 2022 were categorized dependent on timing of repair (early repair [ER] < 24 hours, late repair > 24 hours). Chi-square/Fisher's exact tests were used to compare patient/operative factors and logistic regression analysis was performed to identify factors related to 30-day mortality., Results: Two hundred and twenty two Grade 2 and 3 BTAI treated by TEVAR were analyzed, with 179 in the ER group (81%). There was no difference between the groups regarding Injury Severity Score (ISS), Glasgow Coma Scale, age, or gender. Those in ER were more likely to have a widened mediastinum and a shorter distance from the left subclavian artery to the injury. Thirty-day in-hospital mortality occurred in 14 patients (6%), 2 of which were aortic-related. Thirty-day mortality was associated with a higher baseline incidence of coronary artery disease/peripheral vascular disease/previous cardiac revascularization; lower systolic blood pressure, Glasgow Coma Scale, hemoglobin, platelet count, and blood pH; and higher lactate and ISS on arrival. On multivariate regression analysis, lower hemoglobin, higher ISS, and Grade 3 BTAI were associated with 30-day mortality (P < 0.05), although time to TEVAR was not., Conclusions: In selected patients, delay in performance of TEVAR for Grade 2 and 3 BTAI may be possible. Further research is necessary to identify other factors predictive of success., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Aim: The aim of this work is to illustrate the diversity of vascular injuries in terms of vascular segments or body regions, accident mechanisms and specific patient constellations., Method: A representative case collection was compiled based on current and relevant scientific references in PubMed, own clinical experiences, vascular surgical and novel image-guided interventional options., Results: The diagnostics of vascular injuries in the context of trauma and fractures are based on a thorough physical examination. In addition, the hard and soft signs preferred by the Western Trauma Association should be included in the decision. Doppler ultrasonography examination is the safest and gentlest noninvasive examination procedure for a suspected vascular injury due to repeatable and comparative measurements. The stabilization of a fracture, ideally using an external fixator, should be performed before vascular reconstruction whenever possible, unless massive bleeding, hypovolemic shock or a rapidly spreading hematoma represent an immediate indication for surgery. In pediatric supracondylar fractures, avascular injury without relevant ischemia has frequently been described (pink pulseless hand). In this case, the fracture should first be reduced as the pulse often recovers. Due to the increasing availability, good technical handling and high technical success rate as well as the relatively limited interventional trauma, endovascular treatment of traumatic vascular injuries has become widely accepted. Traumatic aortic ruptures are associated with a high mortality even at the accident site. Rapid endovascular treatment using a stent prosthesis significantly increases the injured person's chances of survival., Conclusion: Vascular injuries in connection with fractures or multiple injuries require interdisciplinary cooperation between the specialties involved., Competing Interests: Einhaltung ethischer Richtlinien. Interessenkonflikt: U. Barth, S. Piatek, M. Stojkova, H. Krause, F. Meyer und Z. Halloul geben an, dass kein Interessenkonflikt besteht. Für diesen Beitrag wurden von den Autor/-innen Studien an Menschen, aber nicht an Tieren durchgeführt. Für die aufgeführte Studie gilt die angegebene ethische Richtlinie. Es liegt kein Bildmjaterial über Patient/-innen vor, die darüber zu identifizieren sind., (© 2024. The Author(s).)

Background: Popliteal artery injuries (PAIs) may have amputation rates as high as 20%. This study focuses on identifying risk factors associated with major amputations following PAIs in a large single-center cohort. Additionally, we assess the impact of repairing or ligating concomitant popliteal vein injuries., Methods: A retrospective chart review encompassing 2011 to 2023 was conducted at a large urban level 1 trauma center. Patients with PAIs were included. Demographics and clinical data were analyzed, and univariate and multivariate evaluations identified significant risk factors for amputation. In patients with concomitant popliteal vein injuries, we compared outcomes between those who underwent popliteal vein repair and ligation., Results: One hundred eighty eight patients with PAIs were identified; 10 underwent index amputation and were excluded. Univariate analysis followed by multivariate analysis revealed that obesity (P = 0.0132) and neurologic deficits on arrival (P = 0.0096) were associated with amputation. In the subgroup with popliteal vein injuries (N = 93), there was no significant difference in amputation rates between those who had vein repair (P = 0.21) and those who underwent ligation (P = 0.84) on logistic regression analysis. Likewise, popliteal vein ligation did not impact duration of fasciotomy closure (P = 0.20) or skin graft area (P = 0.48) based on linear regression analysis., Conclusions: Our study suggests that major amputations following PAIs are more likely in obese patients with neurologic deficits. It also suggests that venous ligation in cases of concomitant popliteal vein injuries does not significantly impact early limb salvage rate. Further research is needed to determine the optimal approach for managing concomitant popliteal vein injuries., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: This study highlights the prevalence and conservative management strategies of iatrogenic ascending aortic dissection after percutaneous intervention (PCI) of chronic total occlusion (CTO)., Methods: Retrospective analysis on patients who underwent CTO PCI from one medical center from 2020 to 2022 was performed by two operators. Data was obtained from the Prospective Global Registry for the Study of CTO database., Results: Out of 318 patients, there were six reported cases of iatrogenic ascending aortic dissection. The causes of dissection included guiding catheter trauma, antegrade injection, two retrograde injection, and two cases of balloon rupture after lithotripsy. IVUS-guided stenting of the coronary back to the origin to seal the entry of the dissection flap occurred in two patients. All patients had a conservative management approach. No patient had to undergo urgent surgery., Conclusion: While the incidence remains rare, complications, including aortic dissection, are more frequent in CTO PCI as compared to non-CTO PCI. IVUS can be used to complete coronary intervention so long as the patient remains clinically and hemodynamically stable. Patients should have formal imaging with either transesophageal echocardiogram or computed tomography angiography. The outcomes of patients who experience iatrogenic aortic dissection during CTO PCI with stable coronary disease seem to be better than in patients with acute coronary syndrome., (© 2024 The Author(s). Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.)

Background: Supracondylar humerus fractures (SCHF) in children are common and can lead to serious complications, including neurovascular injury. The optimal management of children with a 'pink pulseless' hand following such a fracture is unclear. This study aimed to ascertain an appropriate therapeutic approach for children with SCHF and a pink pulseless hand. Methods: A retrospective analysis of medical records from paediatric patients under 16 years old with SCHF and clinically perfused but pulseless hands between 1 January 2016 and 30 June 2021 was conducted. Clinical characteristics, imaging, treatment processes and follow-up results were analysed to predict arterial injuries requiring vascular repair and determine the optimal timing for exploratory surgery. Results: The study included 88 patients, predominantly male (58%) with an average age of 6 years. Most fractures resulted from falls onto outstretched arms. Satisfactory outcomes, indicated by the return of the pulse following closed reduction and percutaneous pinning (CRPP) alone, were seen in 66% of patients, negating the necessity for vascular exploration. Amongst patients with a persistently absent radial pulse 72 hours after CRPP, 83% were diagnosed with brachial artery injuries, with all such patients experiencing recurrent pulse loss after surgery. Conclusions: Urgent reduction and CRPP are effective initial treatments for children with SCHF and a pink pulseless hand. Immediate vascular exploration is generally not necessary in these patients. Further research is needed to determine the optimal management for persistent pulselessness and recurrent pulse loss. Level of Evidence: Level IV (Therapeutic).

Background: Blunt thoracic aortic injury (BTAI) represents one of the most devastating scenarios of vascular trauma. Different management strategies are available with varying clinical outcomes. However, thoracic endovascular aortic repair (TEVAR) has become the first-line option for most BTAI patients, mainly owing to its minimally invasive nature, yielding improved immediate results. This meta-analysis aims to investigate mortality, long-term survival, and reintervention following TEVAR in BTAI., Material and Methods: A systematic review conducted a comprehensive literature search on multiple electronic databases using strict search terms. Twenty-seven studies met the set inclusion/exclusion criteria. A proportional meta-analysis of extracted data was conducted using the Comprehensive Meta-Analysis Software, v.4., Results: 1498 BTAI patients who underwent TEVAR were included. Using the SVS grading system, 2.6% of the population had Grade 1 injuries, 13.6% Grade 2, 62.2% Grade 3, 19.6% Grade 4, and 1.9% unspecific. All-cause mortality did not exceed 20% in all studies except one outlier with a 37% mortality rate. Using the random effects model, the pooled estimate of overall mortality was 12% (95% confidence interval [CI], 5.35-8.55%; I 2  = 70.6%). This was 91% (95% CI, 88.6-93.2; I 2  = 30.2%) at 6 months, 90.1% (95% CI, 86.7-92.3; I 2  = 53.6%) at 1 year, 89.2% (95% CI, 85.2-91.8; I2 = 62.3%) at 2 years, and 88.1% (95% CI, 83.3-90.9; I 2  = 69.6%) at 5 years. Moreover, the pooled estimate of reintervention was 6.4% (95% CI, 0.1-0.49%; I 2  = 81.7%)., Conclusions: Despite the high morbidity and mortality associated with BTAI, TEVAR has proven to be a safe and effective management strategy with favorable long-term survival and minimal need for reintervention. Nevertheless, diagnosis of BTAI requires a high index of suspicion with appropriate grading and prompt transfer to trauma centers with appropriate TEVAR facilities., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Coronary artery perforation (CAP) is a rare but serious complication of Percutaneous coronary intervention (PCI) with significant morbidity and mortality. Traditional management involves the use of covered stents, yet alternative interventions may be necessary. To report a unique case of CAP managed effectively with a drug-coated balloon, highlighting a novel application of this technology in emergency PCI., Case Presentation: A 73-year-old male with a history of chronic angina, hypertension, and diabetes underwent PCI for severe stenosis in the mid-left anterior descending (LAD) artery. During the procedure, a large vessel CAP occurred. Immediate management included hemodynamic stabilization via fluid resuscitation and dopamine administration, followed by the deployment of drug-coated balloons instead of the conventional covered stent to seal the perforation. The intervention successfully sealed the perforation with restoration of thrombolysis in myocardial infarction 3 flow, and the patient remained hemodynamically stable. Follow-up over six months showed no adverse cardiovascular events and normal cardiac function was maintained., Conclusions: This case demonstrates the potential of drug-coated balloons as a feasible alternative to covered stents in managing CAP, particularly in large vessel perforations. Further research is warranted to assess the long-term safety and efficacy of this approach., Competing Interests: Declarations. Ethics approval and consent to participate: This report was approved by the Ethics Committee of Bayannaoer Hospital. Informed consent for the study has been obtained through communication with the patient and their family members. Competing interests: The authors declare no competing interests. Patient consent for publication: The patient has provided informed consent for publication of the case., (© 2024. The Author(s).)

Purpose: The purpose of this paper is to compile and present all of the reported vascular complications that resulted from common non-vascular abdominal procedures in the literature. Non-vascular procedures include, though are not limited to, percutaneous abscess/fluid collection drainage (PAD), percutaneous nephrostomy (PN), paracentesis, percutaneous transhepatic cholangiography (PTC)/percutaneous biliary drainage (PBD), percutaneous biliary stone removal, and percutaneous radiologic gastrostomy (PG)/percutaneous radiologic gastrojejunostomy (PG-J). By gathering this information, radiologists performing these procedures can be aware of the associated vascular injuries, as well as take steps to minimize risks., Methods: A literature review was conducted using the PubMed database to catalog relevant articles, published in the year 2000 onward, in which an iatrogenic vascular complication occurred from the following non-vascular abdominal procedures: PAD, PN, paracentesis, PTC/PBD, percutaneous biliary stone removal, and PG/PG-J. Biopsy and tumor ablation were deferred from this article., Results: 214 studies met criteria for analysis. 28 patients died as a result of vascular complications from the analyzed non-vascular abdominal procedures. Vascular complications from paracentesis were responsible for 19 patient deaths, followed by four deaths from PTC/PBD, three from biliary stone removal, and two from PG., Conclusion: Despite non-vascular percutaneous abdominal procedures being minimally invasive, vascular complications still can arise and be quite serious, even resulting in death. Through the presentation of vascular complications associated with these procedures, interventionalists can improve patient care by understanding the steps that can be taken to minimize these risks and to reduce complication rates., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Blunt traumatic thoracic aortic injuries (BTAIs) are associated with a high mortality rate. Thoracic endovascular aortic repair (TEVAR) is the most frequently used surgical strategy in patients with BTAI, as it offers good short- and middle-term results. Previous studies have reported an abnormally high prevalence of hypertension (HT) in these patients. This work aimed to describe the long-term prevalence of HT and provide a comprehensive evaluation of the biomechanical, clinical, and functional factors involved in HT development., Methods: Twenty-six patients treated with TEVAR following BTAI with no history of HT at the time of trauma were enrolled. They were matched with 37 healthy volunteers based on age, sex, and body surface area and underwent a comprehensive follow-up study, including cardiovascular magnetic resonance, 24-hour ambulatory blood pressure monitoring, and assessment of carotid-femoral pulse wave velocity (cfPWV, a measure of aortic stiffness) and flow-mediated vasodilation., Results: The mean patient age was 43.5 ± 12.9 years, and the majority were male (23 of 26; 88.5%). At a mean of 120.2 ± 69.7 months after intervention, 17 patients (65%) presented with HT, 14 (54%) had abnormal nighttime blood pressure dipping, and 6 (23%) high cfPWV. New-onset HT was related to a more proximal TEVAR landing zone and greater distal oversizing. Abnormal nighttime blood pressure was related to high cfPWV, which in turn was associated with TEVAR length and premature arterial aging., Conclusions: HT frequently occurs otherwise healthy subjects undergoing TEVAR implantation after BTAI. TEVAR stiffness and length, the proximal landing zone, and distal oversizing are potentially modifiable surgical characteristics related to abnormal blood pressure., (Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Injury to the popliteal artery after knee dislocation, if not promptly diagnosed and properly treated, can have devastating results. The purpose of this retrospective study was to describe the diagnostic and the treatment protocol we use, as well as provide long-term outcomes for a series of patients treated in our tertiary hospital, emphasizing on the importance of ankle-brachial index (ABI) measurement as an integral component of the diagnostic approach., Methods: A retrospective analysis of all admissions to our hospital trauma center between November 1996 and July 2023, with a diagnosis of knee dislocation and the presence or absence of concomitant arterial injury resulting from blunt high-energy trauma, was conducted. Before 2006, digital subtraction angiography (DSA) and/or computed tomography angiography (CTA) were part of the diagnostic approach (group A). After 2006, the ABI was used as a first-line test to diagnose arterial damage (group B). The Tegner and Lysholm scores were chosen to assess patients' postoperative impairment between groups, taking also into account the presence or absence of vascular injury. The Mann-Whitney U test and a univariate analysis of variance were used for the statistical analysis of scores., Results: Overall, 55 patients were identified, and 21 of them (38.2%) had injuries to the popliteal artery, all of which were treated with a reversed great saphenous venous bypass. Out of the 21 patients, 4 (4.3%) developed compartment syndrome, which was treated with fasciotomies, and 1 leg (1.8%) was amputated above the knee. With no patients lost to follow-up, all but one (95%) of the vascular repairs are still patent, and the limbs show no signs of ischemia after a mean follow-up of 6 years. The Tegner and Lysholm score means were similar between groups A and B and independent of the presence of vascular injury and the diagnostic protocol used. Interestingly, an ABI below 0.9 proved to be predictive of arterial injury., Conclusions: A high level of awareness for the presence of popliteal artery injury should exist and an ABI measurement should be routinely performed in the management of all cases of knee dislocation. This way, fewer patients will undergo unnecessary CTA scanning, and hardly any popliteal artery injuries can go missing, as suggested by our study., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Dry tamponade is a rare complication of percutaneous coronary intervention. It encompasses a heterogenous pathophysiology and is used to describe hemodynamic compromise secondary to a coronary artery perforation, without free-flowing fluid in the pericardium. Tamponade physiology can result from compressive epicardial, intramyocardial, subepicardial hematomas, or dissecting intramyocardial hematomas. The diagnosis of dry tamponade requires hemodynamic derangement in the context of a compressive hematoma as demonstrated by imaging. Although echocardiography can often help identify dry tamponade, additional studies including right heart catheterization, computed tomography, or cardiac magnetic resonance imaging can inform the exact mechanism and help guide management. This article describes a case of dry tamponade, reviews the existing literature on the topic, and offers expert recommendations on diagnosis and management., (© 2024 Wiley Periodicals LLC.)

Mitral valve repair or replacement poses a potential risk of injury to the left circumflex coronary artery (LCx). Such injuries can arise from either direct LCx injury caused by encircling or transfixing stitches, or indirect occlusion resulting from the distortion of adjacent tissues. We provide and illustrate a representative image depicting LCx distortion. Additionally, we offer guidance to aid angiographers in comprehending the angiographic appearance and the underlying mechanism of occlusion., (© 2024 Wiley Periodicals LLC.)

Although iatrogenic pseudoaneurysm is an infrequent complication, it can be life threatening if ruptured. There are several treatment methods for managing this complication. This case report demonstrates a technique using ultrasonography-guided suture-mediated vascular closure devices without angiography to successfully treat iatrogenic superficial femoral pseudoaneurysm following an unintended hemodialysis catheter insertion. In particular, when it is difficult to use a contrast due to a patient's condition as in this case, suture-mediated vascular closure device with ultrasonography guidance can be used as a therapeutic method., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Intrapelvic hemorrhage following pelvic fractures, including pelvic ring and acetabular fractures, originates from the venous system and the fracture. Arterial injury often causes significant bleeding and hemodynamic instability. The superior gluteal artery (SGA) is a frequently injured artery in patients with pelvic fractures. This study investigated the incidence and pattern of SGA injuries associated with pelvic fractures., Methods: We retrospectively reviewed the medical records of patients with pelvic fractures who visited our institution between January 2016 and April 2022. Patients who underwent angiography for suspected arterial injury and SGA embolization were identified. Furthermore, the demographics and patterns of pelvic fractures were evaluated., Results: In total, 2042 patients with pelvic fractures visited our trauma emergency department and 498 patients (24.4%) underwent embolization for arterial injuries. Of these, 30 patients (1.5% of the total and 6.0% of the patients who underwent procedures) received embolization therapy of the main trunk of the SGA. The mean age of patients was 51.2 (23-85 years), and the injury mechanisms were all high-energy injuries. There were 19 pelvic ring injuries, eight acetabular fractures, and three combined injuries. Acetabular fractures involved mostly both columns. The three combined injuries were lateral compression involving both columns, vertical shear involving both columns, and lateral compression with T-type fractures. Twelve (40.0%) occurred through the sciatic notch of different patterns., Conclusions: SGA injury occurred in 1.5% of all pelvic fractures and was identified in 6% of patients receiving embolization. SGA injury occurs through various injury mechanisms and fracture patterns, even in the absence of a fracture in the sciatic notch. However, no conclusions could be drawn in this study on the association between SGA injuries, injury mechanisms, and fracture patterns. Since the prediction of SGA injury by fracture pattern is limited, angiography should be performed regardless of fracture pattern when an injury is suspected., Competing Interests: Declaration of competing interest The authors declare that they have no competing interests., (Copyright © 2023 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Objectives: Thoracic endovascular aortic repair (TEVAR) is the preferred treatment for severe blunt thoracic aortic injuries (BTAI). Successful outcomes rely on accurate endograft sizing, but initial imaging may underestimate aortic diameters. This study examines the impact of intravascular ultrasound (IVUS) on endograft sizing and clinical outcomes in BTAI patients., Methods: A prospectively collected multi-institutional dataset from the Aortic Trauma Foundation was analyzed. Patients with BTAI undergoing TEVAR with IVUS were compared to patients who underwent TEVAR alone. Demographics and operative variables were compared, focusing on IVUS effects on endograft sizing by examining maximal proximal and distal aortic diameter on initial CT imaging compared to the graft diameters used during TEVAR., Results: 293 patients underwent TEVAR for BTAI with IVUS utilized in 124 cases (42.3%). The average graft size in the IVUS and non-IVUS groups were similar proximally (26.91 ± 4.3 mm IVUS vs 27.77 ± 4.7 mm non-IVUS, P = 0.116) and distally (25.96 ± 4.7 mm IVUS vs 26.51 ± 4.7 mm non-IVUS). IVUS did not impact the difference between graft size and initial CT measurements proximally (4.32 ± 4.8 mm IVUS vs 4.23 ± 3.9 mm non-IVUS, P = 0.859) or distally (4.17 ± 5.9 mm IVUS vs 4.50 ± 4.3 mm non-IVUS, P = 0.606). Although delayed hemorrhagic and ischemic stroke occurred less frequently in IVUS patients (0.8% IVUS vs 7.1% non- IVUS, P = 0.024), in-hospital mortality was similar between groups (5.6% IVUS vs 7.7% non-IVUS, P = 0.581)., Conclusions: IVUS is not associated with significant changes in endograft sizing compared to sizing based on CT scan alone in BTAI patients. IVUS was not associated with differences in mortality but was associated with a decrease in delayed hemorrhagic and ischemic stroke. Routine IVUS in BTAI patients may not be necessary for accurate sizing, but there may be a relationship between IVUS and stroke., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background/objective: Visual impairment affects 55%-80% of medial sphenoid wing meningiomas (mSWMs) patients, making optic nerve decompression a critical surgical goal. Complete resection often leads to better visual outcomes. However, involvement of critical neurovascular structures increases postoperative morbidity and mortality, with vascular injury reported in 18%-20% of cases. This study aims to evaluate the relationship between the extent of resection (EOR), visual outcomes, and the incidence of vascular injury, seeking to identify the optimal surgical approach for mSWMs., Methods: We retrospectively analyzed data from patients undergoing surgery for mSWM at our tertiary care center from January 2001 to December 2021. Inclusion criteria included histopathologically confirmed globoid mSWMs (N = 89). Patients with recurrent tumors (n = 14) or lost to follow-up (n = 9) were excluded. We classified patients into 2 groups based on EOR using Simpson's grade: Group 1 (good-resection,Simpson Grade-I/II,n = 51) and Group 2 (poor-resection,Simpson Grade III/IV, n = 15)., Results: Among 66 (=N) patients, visual impairment was the most common symptom (81.8%), followed by headaches (77.3%) and seizures (27%). T2-hyperintensity on magnetic resonance imaging [(OR:5.4, 95%CI:1.5-18.6) (P-value<0.01)] and cavernous sinus-extension [(OR:3.9, 95%CI:1.1-13.1) (p-value-0.02)] were independent significant predictors of poor resection. Visual status was preserved in 90.3% of Group-1 and 86.6% of Group-2, with no significant difference based on EOR. Vascular involvement was noted in 87.9%, higher than the vessel encasement (>180 0 ) (57.6%, P = 0.04). Vessel injury occurred in 7.8% of Group-1 and 6.6% of Group-2, with no significant impact on EOR., Conclusions: Cavernous sinus-extension and T2-hyperintensity predict poor resection rates in mSWMs. While visual outcomes are not directly affected by EOR, long-term visual status may decline due to tumor recurrence and radiotherapy. Vascular injury incidence is not associated with EOR. Thus, the "maximal safe resection" of mSWMs involves a surgical strategy balancing targeted aggressive and conservative resection for maximal cytoreduction and functional preservation., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Over the past 30 years, there has been a major shift in the management of liver trauma. Contained hepatic vascular injuries (CHVI), including pseudoaneurysms and arteriovenous fistulas, are often feared because of the risk of secondary hemorrhage. However, little is known about CHVI. There are no guidelines for their management. Our aim was to validate the risk factors for CHVI, to identify the associated morbidities, and to establish a management protocol., Materials and Methods: A retrospective study of 318 liver trauma cases from a level 1 trauma center over the past 15 years, comparing the presence or absence of CHVI. Univariable and multivariable analyses were conducted. The treatment used to manage CHVI was also compared., Results: Liver trauma with the following characteristics, AAST grade ≥III, bilateral injuries, and laceration-type lesions, were associated with a higher risk of CHVI. Grade AAST ≥III and bilateral injuries were confirmed in a multivariable study with odds ratios as high as 4.0 and 3.5, respectively. CHVI was associated with significantly more delayed bleeding and controlled computed tomography. After analyzing the noninterventional management of CHVI less than 2 cm, a management algorithm is proposed., Conclusions: This retrospective unicentric study and literature review provide additional insight into the patient profile at risk for developing CHVI, its associated morbidity, and its management., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Coronary perforation (CP) poses a significant risk of morbidity and mortality, particularly, in patients with a history of cardiac surgery. The occurrence of loculated pericardial effusion presents distinctive challenges in these postcardiac surgical patients. This study delves into the complexities arising from the formation of loculated pericardial effusions subsequent to CP, with a specific focus on the loculated effusion in the posterior wall leading to left atrial compression syndrome. This analysis is dedicated to elucidating pathophysiology diagnostic and treatment strategies tailored for addressing left atrium compression syndrome, providing invaluable insights into the intricacies of diagnosing, treating, and managing this entity in the postcardiac surgical patient., (© 2024 Wiley Periodicals LLC.)

Competing Interests: Funding Support and Author Disclosures The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Transfemoral transcatheter aortic valve replacement is the preferred primary access route whenever possible. Despite advancements in expertise and delivery system profiles, complications associated with the primary femoral access still significantly affect procedural morbidity and outcomes. The current standard for accurate main access planning involves proper preprocedural evaluation guided by computed tomography. Several baseline clinical and anatomical features serve as predictors for the risk of vascular injury occurring during or after transcatheter aortic valve replacement. In this paper, we aimed at reviewing the most up-to-date knowledge of the topic for a safe transfemoral access approach according to a paradigm we have called "PIGTAIL.", (© 2024 The Author(s). Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.)

Background: Trauma care depends on a complex transfer system to ensure timely and adequate management at major trauma centers. Patient outcomes depend on the reliability of triage in local or community hospitals and access to tertiary or quaternary trauma institutions. Patients with polytrauma, extremity trauma, or vascular injuries require multidisciplinary management at trauma hospitals. Our study investigated outcomes in this population at a level one trauma center in San Bernardino County, the largest geographic county in the contiguous United States., Methods: We conducted a retrospective review of all patients with extremity trauma who presented to a single level 1 trauma center over 10 years. The cohort was divided into following two groups: 1. transferred from another medical center for a higher level of care or 2. those who directly presented. Overall, 19,417 patients were identified, with 15,317 patients presenting directly and 3,830 patients transferred from an outside hospital. Extremity of vascular injuries was observed in 268 patients. Demographic data were ascertained, including the injury severity score, mechanism of injury, response level, arrival method, tertiary center emergency department disposition, and presence of vascular injury in the upper or lower extremities. Univariate and multivariate analyses were performed to assess patient mortality., Results: A total of 268 patients with vascular injuries were analyzed, including 207 nontransferred and 61 transferred patients. In the univariate analysis, injury severity score means were compared at 11.4 in nontransferred patients versus 8.4 in transferred (P < 0.001), 50% of blunt injury in the nontransferred group, and 28% in the transferred group (P < 0.001); in-hospital mortality was 4% in nontransferred patients versus 28% in the transferred group (P < 0.001). Multivariate logistic regression demonstrated that mortality is 8 times more likely if a patient with vascular extremity injuries is transferred from an outside hospital. A 10% mortality rate was observed in patients without blood transfusion within 4 hr of arrival to the trauma center and 3% mortality in transferred patients transfused blood., Conclusions: Extremity trauma with vascular injury can be lethal if managed appropriately. Patients transferred to our level 1 trauma center had a substantial increase in mortality compared with nontransferred patients. Furthermore, the transfer distance was associated with increased mortality. Further research is required to address this vulnerable patient population., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to demonstrate the safety and effectiveness of a low-profile thoracic endograft (19-23 French) in subjects with blunt traumatic aortic injury., Methods: A prospective, multicenter study assessed the RelayPro thoracic endograft for the treatment of traumatic aortic injury. Fifty patients were enrolled at 16 centers in the United States between 2017 and 2021. The primary endpoint was 30-day all-cause mortality., Results: The cohort was mostly male (74%), with a mean age of 42.4 ± 17.2 years, and treated for traumatic injuries (4% Grade 1, 8% Grade 2, 76% Grade 3, and 12% Grade 4) due to motor vehicle collision (80%). The proximal landing zone was proximal to the left subclavian artery in 42%, and access was primarily percutaneous (80%). Most (71%) were treated with a non-bare stent endograft. Technical success was 98% (one early type Ia endoleak). All-cause 30-day mortality was 2% (compared with an expected rate of 8%), with an exact two-sided 95% confidence interval [CI] of 0.1%, 10.6% below the performance goal upper limit of 25%. Kaplan-Meier analysis estimated freedom from all-cause mortality to be 98% at 30 days through 4 years (95% CI, 86.6%-99.7%). Kaplan-Meier estimated freedom from major adverse events, all-cause mortality, paralysis, and stroke, was 98.0% at 30 days and 95.8% from 6 months to 4 years (95% CI, 84.3%-98.9%). There were no strokes and one case of paraplegia (2%) during follow-up., Conclusions: RelayPro was safe and effective and may provide an early survival benefit in the treatment of blunt traumatic aortic injury., Competing Interests: Disclosures All authors were principal investigators in the study and as such received research grants to conduct the study. B.S. has been paid a consulting fee by Terumo Corporation for an unrelated project., (Copyright © 2024 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Vascular complications (VCs) associated with extracorporeal membrane oxygenation (ECMO) during index hospitalization are prevalent and associated with increased mortality. Few studies have evaluated late VCs following ECMO; this study aims to assess occurrence and management practices of late VCs following discharge., Methods: A retrospective single-institution review was performed of all patients surviving initial hospitalization after being cannulated for central or peripheral veno-venous (VV) or veno-arterial (VA) ECMO between January 1, 2019, and December 31, 2020. Primary outcomes were to categorize and determine the rate of late VCs. Late VCs were defined as any cannulated vessel injury resulting from ECMO cannulation presenting after discharge from index hospitalization. Analysis was conducted by cannulated vessel and stratified by VV or VA ECMO configurations., Results: A total of 229 patients were identified, of which 50.6% (n = 116) survived until discharge. Late VCs occurred in 7.8% of the surviving cohort (n = 9/116); with a median time until presentation of 150 days (interquartile range, 83-251 days). The most common late VC was infection (n = 5; 55.6%) followed by progression to limb-threatening ischemia (n = 4; 44.4%). Urgent procedures were required in 55.6% of patients (n = 5), whereas 44.4% (n = 4) were elective interventions. Interventions performed for management of late VCs included lower extremity arterial revascularization (n = 6; 66.7%), major (n = 1; 11.1%) or minor amputation (n = 1; 11.1%), and wound debridement (n = 1; 11.1%). The majority of patients presenting with late VCs had initially been cannulated for peripheral VA ECMO (n = 8; 88.9%), and one patient (11.1%) was cannulated for peripheral VV ECMO. VCs during index hospitalization were seen in 77.8% of patients (n = 7) returning with late VCs. Odds for late VCs were significantly increased in patients that had been cannulated for ECMO as part of extracorporeal cardiopulmonary resuscitation (odds ratio, 8.4; P = .016) and in cases where patients had experienced an index VC during index hospitalization (odds ratio, 19.3; P = .001)., Conclusions: Late vascular complications after peripheral ECMO cannulation are not rare, particularly after arterial cannulation. Patients should be followed closely early after surviving ECMO with wound evaluation and formal assessment of perfusion with ankle-branchial indices in the cannulated limb., Competing Interests: Disclosures A.W.B. reports consulting for Artivion, Cook Medical, Medtronic, Philips, and Terumo Aortic; and research support from Cook Medical, Medtronic, Philips, Terumo Aortic, W.L. Gore & Associates (all proceeds to the U. of Alabama at Birmingham)., (Copyright © 2024 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Identification of vascular injuries is crucial for complete postmortem evaluation and understanding of trauma deaths by the Medical Examiner. Some vascular injuries are difficult to evaluate due to challenging anatomic locations, especially in the head and neck. Documenting injuries of the facial and vertebral arteries is challenging and necessitates time-consuming dissections that can create artifacts and disfigurement. In busy medical examiner offices with a significant number of traumatic injuries, finding a creative solution to employ reliable postmortem angiography is desirable. At the Office of the Chief Medical Examiner for the State of Maryland (OCME), we created and effectively implemented a selective angiography procedure using traditional indwelling Foley catheters and water-soluble barium swallow contrast to evaluate arterial injuries using either digital radiography or computed tomography imaging modalities. This technique and imaging interpretation can be performed by a medical examiner or forensic pathology fellow after basic technical training and basic radiology training. This study outlines the technique, methods, and utilization of the procedure and describes the findings of six deaths due to vascular lesions from different injury mechanisms and disease processes and describes the ease of implementation on a broader scale in busy Medical Examiner's offices., (© 2024 American Academy of Forensic Sciences.)

Purpose: To evaluate the optimal sizing of an aortic stent graft in patients with blunt thoracic aortic injury (BTAI), considering the decrease in diameter in hypovolemic status., Materials and Methods: From 2014 to 2020, 25 patients who underwent thoracic endovascular aortic repair (TEVAR) for BTAI were included. Hemodynamic parameters in the emergency room (ER) and just before the main procedure (MP) were collected. The aortic sizes were measured during initial computed tomography (CT) on arrival in the ER, aortography (AG) during TEVAR, and final CT in the outpatient clinic. The appropriateness of the inserted stent graft size was investigated., Results: The mean values of the final CT/initial CT and final CT/initial AG (proximal descending thoracic aorta [pDTA]) were 113% and 105%, respectively. The final CT/initial CT (pDTA; 122.2% vs 108.8%, p=0.01) and final CT/initial AG (pDTA; 113.4% vs 102.1%, p<0.01) were significantly higher in patients with systolic blood pressure (SBP; MP) ≤90 mm Hg. The final CT/initial CT (pDTA; 120.4% vs 109.0%, p=0.03) and final CT/initial AG (pDTA; 111.4% vs 102.6%, p=0.01) were significantly higher in patients with mean blood pressure (MBP; MP) ≤70 mm Hg. On an average, the inserted stent grafts were oversized by 130% on initial AG. Based on the final CT scan, the inserted stent graft was as large as 122%., Conclusion: In the case of hemodynamic instability with SBP (MP) ≤90 mm Hg or MBP (MP) ≤70 mm Hg, despite adequate resuscitation, an oversized TEVAR stent graft of 130% can reduce the occurrence of endoleak and is sufficiently safe., Clinical Impact: Despite sufficient resuscitation, the aorta size measured during TEVAR in patients with hemodynamic instability with systolic BP <90 mmHg and mean BP <70 mmHg may be reduced by more than 15% compared to that in the normal state. In this study, the mean size of the stent grafts were oversized by 130% on initial aortography, but were oversized by 122% based on final CT. When the stent graft was oversized by 130% in TEVAR for hemodynamic unstable patient with BTAI, the patient reached the proper oversizing subsequent to hemodynamic recovery., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Arteriovenous fistulas (AVFs) of the lower extremity are uncommon. The main causes are traumatic or iatrogenic, with 15% of traumatic AVFs occurring in the popliteal vessels. Herein, we present a 60-year-old female with a traumatic AVF caused after a car accident 40 years ago. The patient presented with right leg venous claudication and symptoms of congestive heart failure. Duplex ultrasound of lower limb vessels revealed an AVF at the distal part of the tibiofibular trunk. The patient was successfully managed with an endovascular approach using a coil-assisted covered endovascular repair technique of the tibiofibular bifurcation (CERTIFIB) with excellent results and distal vessels patency. At 3 months follow-up, patient presented with an impressive regression of 3 cm of the lower extremity oedema and improvement of both claudication and heart failure., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Heart failure due to high cardiac output rarely occurs. Few cases of post-traumatic arteriovenous fistula (AVF) as a cause of high-output failure were reported in the literature., Methods: Herein, we report a case of 33-year-old male who was admitted to our institution due to symptoms of heart failure. He reported a gunshot injury of the left thigh 4 months earlier, when he had been shortly hospitalized and discharged 4 days later. Since the gunshot injury he had exertional dyspnea and left leg edema, so the diagnostic procedures were performed., Results: Clinical examination revealed distended neck veins, tachycardia, slightly palpable liver, left leg edema, and thrill over the left thigh. Due to high clinical suspicion, duplex ultrasonography of the left leg was performed that verified femoral AVF. Operative treatment of AVF was made with prompt resolution of symptoms., Conclusions: This case wants to emphasize the importance of proper clinical examination, and duplex ultrasonography in all cases of penetrating injuries., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The characterization of radial artery perforation (RAP) patterns using optical coherence tomography (OCT) has not been well established. This study aimed to identify the characteristic RAP patterns in patients diagnosed through post-procedural OCT examination., Methods: This retrospective study included 1936 consecutive patients who underwent radial artery (RA) OCT following OCT-guided transradial coronary intervention (TRI) from January 2016 to July 2022. Data regarding RAP characteristics were collected through OCT, including the perforation site as well as dimensions such as the length, width, and arc. Furthermore, RAP types were classified as small or large perforations, with a cut-off arc value of ≤90°., Results: RAP, as identified by RA angiography (RAA) during TRI and on post-procedural OCT, was found in 16 out of 1936 patients (0.83 %). RA OCT imaging showed that the median distance between the RA ostium and the perforation site, the perforation length, width, and arc were 30.6 (14.4-42.2) mm, 1.55 (1.03-1.92) mm, 0.74 (0.60-1.14) mm, and 42.5 (25.0-58.1) °, respectively. Small perforations (arc ≤90°) were observed in 14 out of the 16 (87.5 %) patients with RAP. Post-procedural RAA revealed that 15 out of the 16 (93.7 %) patients with RAP had sealed perforations, with the remaining patient requiring external compression., Conclusions: Our findings demonstrated that RAP is uncommon during TRI, with clearly defined characteristic patterns on OCT. Most RAPs are small and tend to spontaneous seal through catheter tamponade., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Pulmonary artery rupture is a rare complication of right heart catheterization characterized by a rapid clinical deterioration and high mortality rate. We present the case of an 89-year-old woman with severe symptomatic aortic stenosis who underwent cardiac catheterization prior to aortic valve replacement. The patient had acute cardiopulmonary deterioration due to pulmonary artery rupture at the time of right heart catheterization, that was successfully sealed by balloon tamponade., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: Traumatic axillary and subclavian artery injuries are uncommon. Limited data are available regarding patient and injury characteristics, as well as management strategies and outcomes., Methods: Retrospective chart review was performed on patients presenting to University of Louisville Hospital, an urban Level One Trauma Center, with traumatic axillary and subclavian artery injuries from 2015-2021. Patients were identified using University of Louisville trauma, radiology, and billing database searches based on ICD9/10 codes for axillary and subclavian artery injuries. Descriptive statistics are expressed as frequencies and percentages. Comparisons were performed using Fisher's Exact and Chi-squared tests., Results: Forty-four patients with traumatic axillary-subclavian arterial injuries were identified for analysis. Blunt and penetrating trauma were equally represented (n = 22 for both). A variety of injury types were seen, including minimal/intimal injury, laceration, pseudoaneurysm, transection, occlusion, and arteriovenous fistula. Management strategies were also variable, including non-operative, endovascular, planned hybrid, open, and endovascular converted to open. In operative patients, revascularization technical success was high (n = 31, 97%) with low likelihood of thrombosis (n = 2, 6%) and no infections. Among all patients, amputation rate was 5% (n = 2) and mortality rate was 9% (n = 3). Regarding arterial involvement, blunt injury was more likely to affect the subclavian (n = 18) than the axillary artery (n = 6) ( P = .04). No significant difference was seen in brachial plexus injury based on artery involved (subclavian = 9 vs axillary = 11, P = .14) or mechanism (blunt = 6 vs penetrating = 11, P = .22). Non-operative management was more likely with subclavian artery injury (n = 11) vs axillary artery injury (n = 1) ( P = .008). There was no significant difference between decision for non-operative (blunt = 9, penetrating = 3) vs operative (blunt = 13, penetrating = 19) management based on mechanism ( P = .09). Transection injury was associated with an open repair strategy (endovascular/hybrid = 1, open/endovascular to open conversion = 11, P = .0003). Of the three patients requiring endovascular to open conversion, two required amputation, which were the only two patients in the study undergoing amputation., Conclusions: Both open and endovascular/hybrid strategies are useful when treating traumatic axillary and subclavian artery injuries and are associated with high likelihood of revascularization technical success, with low rates of thrombosis or infection, when treated promptly at a trauma center with vascular specialists available. Transection injuries were most often treated with open revascularization. Patients undergoing amputation had blunt transection injuries to the subclavian artery and underwent endovascular to open conversion after failed attempts at endovascular revascularization., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: The TOBA (Tack Optimized Balloon Angioplasty) II trial is a prospective, single-arm, multicenter study that investigated Tack treatment for patients with dissection after angioplasty in the superficial femoral artery and/or proximal popliteal artery. The Tack device is a nitinol-based, short (6 mm), stent-like implant with low outward force that can be deployed in a targeted fashion to treat vascular dissection. TOBA II primary results through 12 months have been published previously. This report provides follow-up safety and efficacy results through 24 months (RC)., Methods: The TOBA II trial enrolled 213 patients with Rutherford classification 2 to 4 and a de novo or non-stented restenotic lesion in the superficial femoral artery and/or proximal popliteal artery who developed a dissection of any grade after treatment with plain balloon or drug-coated balloon (DCB) angioplasty. Participants were followed for 30 days, 6 months, 12 months, 24 months, and 36 months following the procedure. Evaluations included clinically driven target lesion revascularization (CD-TLR), ankle-brachial index, Rutherford classification, peripheral artery questionnaire, quality of life assessed by the EQ-5D-3L, and the Walking Impairment Questionnaire., Results: At enrollment, mean age was 68.2 ± 9.1 years, 70.9% were male, and 95.8% of patients were categorized as RC 2 or 3. The distribution of balloon types in the study were standard balloons: 42.3%; and drug-coated balloons: 57.7%. At 24-month follow-up, 167 patients (78.4%) had available data. The overall survival rate at 24 months was 95.4% and there were no major amputations during this time. After 24 months of follow-up, the Kaplan-Meier freedom from CD-TLR was 77.7%. Rutherford classification, ankle-brachial index, and quality of life were significantly improved compared with baseline through 24 months., Conclusions: The TOBA II 24-month data demonstrate durable intermediate-term outcomes with the use of the Tack Endovascular System. Tack deployment was a safe and effective therapeutic option for dissection repair following angioplasty., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Marianne Brodmann is a consultant for Philips, Medtronic, Boston Scientific, Cagent, Biotronik, Cook Medical, MedAlliance, Surmodics, BD Bard, and Shockwave. Martin Werner has no conflicts of interest to declare. Ami Sood is an employee of Philips North America, LLC. William A. Gray is a consultant for Philips.

Background: Pediatric extremity vascular injuries constitute a rare yet serious entity that can lead to serious complications especially if left untreated or become late diagnosed. In our scoping review, we sought to evaluate different characteristics and outcomes of pediatric and combined adult trauma centers (ATCs) in the management of pediatric extremity vascular injury., Methods: We sought to analyze various characteristics and parameters that differentiate a dedicated pediatric and a combined pediatric ATC in terms of effectiveness and quality of care in the acute setting and to describe special features and characteristics of an acute vascular disease that constitute pediatric population unique from the aspect of diagnosis and management. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping reviews guidelines to conduct the study., Results: The search identified 8,815 records in title using MeSH terms from PubMed/MEDLINE database among which 12 studies reporting a total of 2,124 pediatric patients with vascular extremity injuries were included for analysis. Incidence of pediatric extremity vascular injury was 0.5%. Upper extremity injuries were the most frequent presenting in 63% of cases followed by lower extremity injuries in 37% of cases. Blunt injuries were marginally more common than penetrating injuries (58% vs. 42%). In-hospital mortality and morbidity ranged from 13.2% to 0.9% and 13% to 30%, respectively. Limb-salvage rates were high, ranging from 92% to 99%. Furthermore, there are no clearly defined clinical guidelines involving the mode of imaging and diagnosis, the surgical specialties involved and the competency of nursing or medical staff overall., Conclusions: Dedicated children trauma centers theoretically represent the optimal path for acute pediatric trauma admission, especially in complex trauma necessitating vascular reconstruction. However, in the current setting of rapidly increasing health costs and economic crisis worldwide, regional or resource-related factors make this option rather unavailable. In any case, it is imperative the clinicians have a high index of suspicion when confronting with these types of injuries because early diagnosis is highly related with reduced morbidity and superior outcomes., (Copyright © 2024. Published by Elsevier Inc.)

Objective: Vascular surgeons are often called upon to provide emergent surgical assistance to other specialties for iatrogenic complications, both intraoperatively and in the inpatient setting. The management of iatrogenic vascular injury remains a critical role of the vascular surgeon, especially in the context of the increasing adoption of percutaneous procedures by other specialties. This study aims to characterize consultation timing, management, and outcomes for iatrogenic vascular injuries., Methods: This study identified patients for whom vascular surgery was consulted for iatrogenic vascular complications from February 1, 2022, to May 12, 2023. Patient information, including demographic information, injury details, and details of any operative intervention, was retrospectively collected from February 1, 2022, to October 13, 2022, and prospectively collected for the remainder of the study period. Analyses were performed with R (version 2022.02.03)., Results: There were 87 patients with consultations related to iatrogenic vascular injury. Of these, 42 (46%) were female and the mean age was 59 years (±18 years). The most common consulting services were cardiology (32%), cardiothoracic surgery (26%), general surgery (8%), and neurointerventional radiology (10%). Reasons for consultation included hemorrhage (36%), limb ischemia (36%), and treatment of pseudoaneurysm (23%). A total of 24% of consults were intraoperative, 20% of consults related to extracorporeal membrane oxygenation cannulation, and 16% of consults related to ventricular assist devices including left ventricular assist device and intra-aortic balloon pump. The majority of these consult requests (60%) occurred during evening and night hours (5 PM to 7 AM). Emergent intervention was required in 62% of cases and consisted of primary open surgical repair of arterial injury (54%), endovascular intervention (21%), and open thromboembolectomy (15%). Overall, in-hospital mortality for the patient cohort was 20% and the reintervention rate was 23%, reflecting the underlying complexity of the illness and nature of the vascular injury in this patient group., Conclusions: Vascular surgeons play an essential role in managing emergent life-threatening hemorrhagic and ischemic iatrogenic vascular complications in the hospitalized setting. The complications require immediate bedside or intraoperative consult and often emergent open surgical or endovascular intervention. Furthermore, many of these require urgent management in the evening or overnight hours, and therefore the high frequency of these events represents a potential significant resource utilization and workforce issue to the vascular surgery workforce., Competing Interests: Disclosures None., (Copyright © 2024. Published by Elsevier Inc.)

Carotid artery puncture is a common complication of internal jugular vein (IJV) catheterization. However, there are few reports about an aneurysm from the carotid artery that can develop into an occult mediastinal hematoma, leading to airway compression. In this case study, we present the case of a 71-year-old male who experienced an aneurysm and delayed mediastinal hematoma, ultimately resulting in airway compression after right jugular line insertion. Our findings highlight the importance of not only addressing local hematoma formation at the puncture site promptly, but also recognizing the potential for aneurysm extension into the mediastinum and the formation of an occult hematoma, which can lead to airway compression. Additionally, we provide a summary of landmark technique precautions that can help reduce the occurrence of such severe complications., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: Spontaneous renal vessel rupture is a rare clinical emergency. However, pregnancy symptoms and signs are not obvious, and the limited examination methods obscure the observation. Thus, early renal rupture is challenging to detect, leading to misdiagnosis and poor prognosis. This paper aims to improve clinicians' understanding of this disease and reduce the rate of clinical misdiagnosis., Patient Concerns: The patient, aged 23 and 11 weeks pregnant, developed severe right lumbar and abdominal pain for 14 hours after severe nausea, vomiting, and paroxysmal intensification. Color ultrasound of the urinary system at another hospital revealed right kidney stones and right ureter dilation. Thus, the patient came to our hospital for treatment., Diagnoses: Spontaneous renal vessel rupture., Interventions: In this case, the diagnosis of spontaneous renal vascular rupture and hemorrhage was confirmed. Following conservative treatment such as fluid replenishment, blood transfusion, and hemostasis, the patient was given an emergency renal artery embolization due to unstable hemodynamics during treatment and poor conservative treatment effect., Outcomes: Nephrectomy was performed after 1-week follow-up for renal necrosis., Lessons: To avoid missed diagnosis and misdiagnosis, patients with abdominal pain caused by severe vomiting during pregnancy must be closely monitored. Additionally, treatment should be considered individually to ensure the safety of both mother and child. Therefore, spontaneous renal vessel rupture should be considered as the differential diagnosis., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

BACKGROUND Inferior vena cava (IVC) injury is a potentially fatal injury with a high mortality rate of 34-70%. In cases in which the patient's condition is stable, diagnosis by computed tomography (CT) is the criterion standard. Findings on CT include retroperitoneal hematoma around the IVC, extravasation of contrast medium, and abnormal morphology of the IVC. We report a case of an IVC injury that could not be diagnosed by preoperative CT examination and could not be immediately detected during laparotomy. CASE REPORT A 73-year-old woman had stabbed herself in the neck and abdomen at home using a knife. When she arrived at our hospital, we found a stab wound several centimeters long on her abdomen and a cut approximately 15 cm long on her neck. We activated the massive transfusion protocol because she was in a condition of hemorrhagic shock. After blood transfusion and blood pressure stabilization, contrast-enhanced computed tomography (CT) revealed a small amount of fluid in the abdominal cavity. An otorhinolaryngologist performed successful drainage and hemostasis, and a laparotomy was performed. Gastric injury and mesentery injury of the transverse colon were identified and repaired with sutures. Subsequent search of the retroperitoneum revealed massive bleeding from an injury to the inferior vena cava (IVC). The IVC was repaired. Postoperative progress was good, and she was discharged from the hospital 65 days after her injuries. CONCLUSIONS We experienced a case of penetrating IVC injury, which is a rare trauma. Occult IVC injury may escape detection by preoperative CT examination or during laparotomy.

Competing Interests: Funding Support and Author Disclosures Dr Meier has received an institutional grant from Edwards Lifesciences. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Background: Endovascular repair of blunt thoracic aortic injury (BTAI) has dramatically reduced the morbidity and mortality of intervention. Injuries requiring zone 2 coverage of the aorta traditionally require left subclavian artery (LSA) sacrifice or open revascularization. Furthermore, these injuries are associated with an increased risk of in-hospital mortality and long-term morbidity. Here we report 1-year outcomes of total endovascular repair of BTAI with the GORE® TAG® Thoracic Branch Endoprosthesis for LSA preservation., Methods: Across 34 investigative sites, 9 patients with BTAI requiring LSA coverage were enrolled in a nonrandomized, prospective study of a single-branched aortic endograft. The thoracic branch endoprosthesis device allows for graft placement proximal to the LSA and incorporates a single side branch for LSA perfusion., Results: This initial cohort included 8 male and 1 female patient with a median age of 43 (22, 76) and 12 months of follow-up. Five total years of follow-up are planned. All participants had grade 3 BTAI. All procedures took place between 2018 and 2019. The median injury severity score was 2 (0, 66). The median procedure time was 109 min (78, 162). All aortic injuries were repaired under general anesthesia and with heparinization. A spinal drain was used in one patient. Post-deployment balloon angioplasty was conducted in one case at the distal landing zone. There was one asymptomatic LSA branch occlusion 6 months after repair. It was attributed to the purposeful proximal deployment of the branch stent to accommodate an early vertebral takeoff. The occlusion did not require revascularization. There were no strokes, mortalities, or aortic adverse events (migration, endoleak, native aortic expansion, dissection, or thrombosis) through 12 months of follow-up., Conclusions: Initial cohort outcomes suggest that endovascular repair of zone 2 BTAI is feasible and has favorable outcomes using the thoracic branch device with LSA preservation. Additional cases and longer-term follow-up are required for a definitive assessment of the device's safety and durability in traumatic aortic injuries., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)