Arie Bass

Terror Attacks Increase the Risk of Vascular Injuries

Objectives: Extensive literature exists about military trauma as opposed to the very limited literature regarding terror-related civilian trauma. However, terror-related vascular trauma (VT), as a unique type of injury, is yet to be addressed. Methods: A retrospective analysis of the Israeli National Trauma Registry was performed. All patients in the registry from 09/2000 to 12/2005 were included. The subgroup of patients with documented VT (N = 1,545) was analyzed and further subdivided into those suffering from terror-related vascular trauma (TVT) and non-terror-related vascular trauma (NTVT). Both groups were analyzed according to mechanism of trauma, type and severity of injury and treatment. Results: Out of 2,446 terror-related trauma admissions, 243 sustained TVT (9.9%) compared to 1302 VT patients from non-terror trauma (1.1%). TVT injuries tend to be more complex and most patients were operated on. Intensive care unit admissions and hospital length of stay was higher in the TVT group. Penetrating trauma was the prominent cause of injury among the TVT group. TVT group had a higher proportion of patients with severe injuries (ISS ≥ 16) and mortality. Thorax injuries were more frequent in the TVT group. Extremity injuries were the most prevalent vascular injuries in both groups; however NTVT group had more upper extremity injuries, while the TVT group had significantly much lower extremity injuries. Conclusion: Vascular injuries are remarkably more common among terror attack victims than among non-terror trauma victims and the injuries of terror casualties tend to be more complex. The presence of a vascular surgeon will ensure a comprehensive clinical care.

Hypothenar hammer syndrome: apropos of six cases and review of the literature.

Hypothenar hammer syndrome (HHS) is a rather rare condition and is a term used to describe an aneurysm or thrombosis of the ulnar artery. It is considered an occupational or recreational injury and is usually a result of a repetitive trauma to the hypothenar region where the unique anatomy of the Guyon canal allows arterial injury. HHS is one of the less common causes of symptomatic ischemia of the upper extremity. The aim of this article is to describe our experience with six patients. Presenting signs, symptoms, differential diagnoses, and literature review of this probably underdiagnosed syndrome are described. There are two pathologic entities: the aneurysmal type and the thrombotic type. Although most authors recommend watchful observation for the thrombotic type, reconstructive surgery is the treatment of choice for the aneurysmal type.

Effect of Timing of Thrombectomy on Survival of Thrombosed Arteriovenous Hemodialysis Grafts

Background: The use of an arteriovenous (AV) graft for hemodialysis is associated with a relatively high rate of thrombosis. Unfortunately, the urgent thrombectomy is not always readily available. Our aim was to investigate a possible association between the timing of thrombectomy and the patency rates of AV grafts. Methods: A retrospective single-center study on patients who underwent thrombectomy of clotted AV grafts was conducted. According to the time of thrombectomy, all patients were divided into 4 groups. Results: Primary graft patency at 6 months after thrombectomy was 28.3%, with no significant difference between the study groups (P = .161). Secondary graft patency at 6 months was significantly worse in the group that underwent thrombectomy between the third and fifth days than in the whole cohort: 15.4% versus 45.6% (P = .038). Conclusions: Timing of thrombectomy of a clotted AV graft may have a significant impact on the graft survival.

Aortic false aneurysm following blunt trauma of the abdomen.

A post-traumatic false aneurysm of the abdominal aorta was diagnosed 8 years after blunt abdominal trauma with blast, sustained during combat. Severe persistent backache with erosion of D12 and L1 vertebrae were the presenting symptoms. The aneurysm was repaired by tube graft replacement.

Effect of Timing of the First Cannulation on Survival of Arteriovenous Hemodialysis Grafts

The use of an arteriovenous graft as vascular access for hemodialysis is associated with a high rate of patency loss. The influence of timing of the first cannulation of the graft on graft survival has not been sufficiently studied. The purpose of this study was to investigate an association between the timing of the first cannulation of the polytetrafluoroethylene arteriovenous graft and the incidence of 12‐month failure. This is a retrospective study on a cohort of chronic hemodialysis patients treated in a single center. According to the time, in weeks, between graft construction and its first successful cannulation, the grafts were divided into six groups: 2nd, 3rd, 4th, 5th, 6th and 7th or more week after surgery. The primary outcome was primary graft failure at 12 months, defined as the first occurrence of graft thrombosis or any invasive access procedure. The secondary outcome was cumulative graft failure at 12 months, defined as complete loss of the access site for dialysis. Fifty‐eight patients with 64 newly‐created arteriovenous grafts were included in the study. In the whole cohort, the incidence of primary graft failure at 12 months was 72.2%, and the incidence of cumulative graft failure at 12 months was 40.7%. The incidences of primary graft failure and cumulative graft failure at 12 months did not differ significantly between the study groups. In our study, timing of the first cannulation of a new arteriovenous polytetrafluoroethylene graft had no significant impact on graft survival.

Superior mesenteric artery to superior mesenteric vein arteriovenous fistula presenting as abdominal pain and gastrointestinal bleeding 3 years after an abdominal gunshot wound: report of a case and review of the literature.

Traumatic abdominal arteriovenous fistulas (AVFs) are rare. Upon diagnosis, early intervention is mandatory to prevent complications such as hemorrhage, congestive heart failure (CHF), and portal hypertension. Traditionally, surgical ligation of the fistula or resection of the vascular anomaly with either an end-to-end anastomosis or an autogenous reconstruction have been performed. Recently, however, percutaneous endovascular treatment of such AVFs has been increasingly performed, using covered stents or embolization. Herein, we report on a patient in whom laceration of a branch of the superior mesenteric artery (SMA) caused by a gunshot wound (GSW) was primarily repaired. Three years later, a work up for abdominal pain, cherry red stool, and anemia revealed a huge fistula between the SMA and superior mesenteric vein (SMV) accompanied by a smaller fistula between a jejunal artery and the SMV. The fistulas were treated by the endovascular technique.

Civilian casualties of terror-related explosions: the impact of vascular trauma on treatment and prognosis

Objectives A high prevalence (10%) of vascular trauma (VT) was previously described in terror-related trauma as compared with non–terror-related trauma (1%), in a civilian setting. No data regarding outcome of VT casualties of improvised explosive device (IED) explosions, in civilian settings, are available. The aim of the current study is to present the prognosis of civilian casualties of IED explosions with and without VT. Methods A retrospective analysis of the Israeli National Trauma Registry was performed. All patients in the registry from September 2000 to December 2005 who were victims of explosions were included. These patients were subdivided into patients with VT (n = 109) and non-VT (NVT) (n = 1,152). Both groups were analyzed according to mechanism of trauma, type and severity of injury, and treatment. Results Of 1,261 explosion casualties, there were 109 VT victims (8.6%). Patients with VT tended to be more complex, with a higher injury severity score (ISS): 17.4% with ISS 16 to 24 as compared with only 10.5%. In the group of critically injured patients (ISS, 25–75), 51.4% had VT compared with only 15.5% of the NVT patients. As such, a heavy share of hospitals’ resources were used—trauma bay admission (62.4%), operating rooms (91.7%), and intensive care unit beds (55.1%). The percentage of VT patients who were admitted for more than 15 days was 2.3 times higher than that observed among the NVT patients. Lower-extremity VT injuries were the most prevalent. Although many resources are being invested in treating this group of patients, their mortality rate is approximately five times more than NVT (22.9% vs. 4.9%). Conclusions Vascular trauma casualties of IED explosions are more complex and have poorer prognosis. Their higher ISS markedly increases the hospital’s resource utilization, and as such, it should be taken into consideration either upon the primary evacuation from the scene or when secondary modulation is needed in order to reduce the burden of the hospitals receiving the casualties. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level V.

Long-term follow-up of patients after carotid stenting with or without distal protective device in a single tertiary medical center.

Objective: To evaluate the immediate and long-term clinical outcomes after carotid artery stenting (CAS) with and without protection devices (PDs), compared with carotid endarterectomy (CEA). Methods: A total of 116 patients with symptomatic carotid stenosis underwent CAS; 56 patients (48.3%) underwent CAS-PD; and 137 patients underwent CEA. Results: There were more ipsilateral transient ischemic attacks (TIAs) in the CEA group than in CAS-PD and CAS + PD (4 [3%] vs 1 [1.6%] and 0 respectively, P = 0.02). In the CAS-PD group there were more vertebrobasilar TIAs, ipsi- and contralateral strokes, myocardial infarctions, and death rates in the 30-day postprocedural period. After 8-year follow-up, there were 18 (30%) death cases in the CAS-PD group, 10 death cases (17%) in the CAS + PD patients, and 15 death cases (11%) in the CEA group of patients (P = .02). Conclusion: Our data show that CAS + PD was associated with lower rate of vascular complications and mortality compared with CAS-PD and CEA.

Epithelioid hemangioendotheliomia as a rare cause of blue toe syndrome

Blue toe syndrome (BTS), is a well-known entity of toe gangrene and rest pain secondary to micro emboli lodged within the digital arteries. BTS among young patients should alert physicians to look for causes such as trauma, connective tissue disease, hypercoagulability state, and others. We hereby describe a 32-year-old female with right BTS. A mass obstructing 80% of the right popliteal artery lumen was the source of emboli. The histologic results of the replaced arterial segment revealed a thrombus on top of epithelioid hemangioendothelioma. This is the first description of the association between primary vascular tumor and BTS.

Transiliac wing alternate route bypass for infected groin vascular graft.

Groin infection after vascular reconstruction is one of the most severe complications, necessitating aggressive surgical therapy. Maintaining limb perfusion along with removal of an infected graft sometimes requires an unorthodox surgical solution. We describe such an unorthodox surgical approach, in which a new graft was routed from the infrarenal aorta to the anterior tibial artery through the iliac bone wing.