Charles B. Drucker

Management and outcomes of blunt common and external iliac arterial injuries

OBJECTIVE Blunt iliac arterial injuries (BIAI) require complex management but are rare and poorly studied. We investigated the presentation, management, and outcomes of patients with blunt common or external iliac arterial injuries. METHODS We identified and reviewed 112 patients with BIAI admitted between 2000 and 2011 at a Level I trauma center. Patients with common/external iliac artery injuries (CE group) were primarily analyzed, with patients with injuries of the internal iliac artery or its major branches (IB group) included for comparison of pelvic arterial trauma. RESULTS Twenty-four patients had CE and 88 had IB injuries. Mean ages (45 ± 19 years) and gender (86% male) were similar between groups. The mean injury severity score was 40 ± 14 (CE, 36 ± 15; IB, 40 ± 14; P = .19), indicating severe trauma. Twenty (83%) of the CE patients presented with signs of leg malperfusion. Admission factors associated with CE injury were crush mechanism of injury (37% vs 17%; P = .03) and pelvic soft tissue trauma (50% vs 15%; P < .01). The CE group had higher early mortality rates, both within 3 hours of admission (50% vs 19%; P = .04) and prior to iliac intervention (42% vs 3%; P < .01). Among those surviving to management, CE patients were more likely to undergo open repair or revascularization (68% vs 3%; P < .01) and had a higher rate of leg amputation (50% vs 6%; P < .01), with 8/12 (67%) culminating in hemipelvectomy. Risk factors for amputation included leg malperfusion, high-grade pelvic fractures, pelvic soft tissue trauma, and increasing leg injury severity. Overall mortality was 40%, and was similar between the injury groups. Among CE patients, need for amputation, pelvic fractures, and wounds were associated with inpatient mortality. CONCLUSIONS This is the largest series to date of blunt CE injuries and demonstrates distinct clinical features and outcomes for these patients. They have high risk for early death and proximal leg amputation. CE injury is specifically associated with serious open pelvic soft tissue injury, which, along with high-grade pelvic fractures, is a risk factor for amputation and death. On-demand emergent endovascular intervention may play an important role in improving management of these complex injuries.

Patterns and management of blunt abdominal aortic injury.

BACKGROUND Blunt abdominal aortic injury (BAAI) is historically associated with significant morbidity and mortality. Our institutional experience was analyzed to define current patterns of injury and to help guide management. METHODS Adult patients with BAAI between January 2000 and July 2011 were identified from our trauma registry. Medical, radiographic, and autopsy records were reviewed for relevant clinical data. Management and outcomes were compared between patients with minimal aortic injury limited to the intima (MAI) compared to more significant aortic injury (SAI). RESULTS Nine patients had MAI and 8 had SAI, including 2 dissections, 2 pseudoaneurysms, 2 branch avulsions, 1 thrombosis, and 1 transection. The MAI and SAI groups had similar demographics and patterns of injury, and all patients had significant polytrauma, with a mean injury severity score of 42. More MAI than SAI patients were managed nonoperatively (100% vs. 38%; P=0.01). All observed patients underwent repeat imaging during the index admission, 85% within 72 hours, and no observed lesions led to malperfusion, death, or progression during the index admission. One MAI progressed to a pseudoaneurysm within 8 months. Five SAI patients underwent aortic-related repairs, including 2 endovascular stent grafts, 2 open primary repairs, and 1 axillobifemoral bypass. Overall, 15 (88%) patients underwent procedures for any injury-9 required laparotomy (53%) and 2 underwent thoracotomy. There were 6 (35%) deaths, 2 attributable to aortic injury-1 from hemorrhage and 1 from hyperkalemic cardiac arrest after prolonged ischemia from infrarenal aortic occlusion. Among patients who survived the initial resuscitation, SAI was associated with a significantly higher mortality rate compared to MAI (50% vs. 0%; P=0.03). CONCLUSIONS Patients with MAI are at low risk of complications and may be considered for observation. Patients with SAI requiring intervention manifest clinically and/or radiographically at presentation. Those not associated with bleeding, malperfusion, or thromboembolism may be observed with interval imaging. For all observed patients, long-term surveillance is required to document complete resolution or stability, because even MAI can progress to a more complex lesion.

Implications of concomitant hypogastric artery embolization with endovascular repair of infrarenal abdominal aortic aneurysms

Objective: Hypogastric artery embolization (HAE) is associated with significant risk of ischemic complications. We assessed the impact of HAE on 30‐day outcomes of endovascular aneurysm repair (EVAR) of infrarenal abdominal aortic aneurysms. Methods: We queried the American College of Surgeons National Surgical Quality Improvement Program database from 2011 to 2014 to identify and to compare clinical features, operative details, and 30‐day outcomes of EVAR with those of concomitant HAE with EVAR (HAE + EVAR). Multivariate analysis was performed to determine preoperative and intraoperative factors associated with development of significant complications observed in patients with HAE + EVAR. Results: In a cohort of 5881 patients, 387 (6.6%) underwent HAE + EVAR. Compared with EVAR, a higher incidence of ischemic colitis (2.6% vs 0.9%; P = .002), renal failure requiring dialysis (2.8% vs 1%; P = .001), pneumonia (2.6% vs 1.3%; P = .039), and perioperative blood transfusion (17% vs 13%; P = .024) was noted after HAE + EVAR. Thirty‐day thromboembolic events, strokes, myocardial infarction, lower extremity ischemia, reoperation, and readmission rates were not significantly different (P > .05). Mortality at 30 days in HAE + EVAR patients was 4.1% compared with 2.5% with EVAR (P = .044). HAE was independently associated with increased risk of colonic ischemia (adjusted odds ratio, 2.98; 95% confidence interval, 1.44‐6.14; P = .003) and renal failure requiring dialysis (adjusted odds ratio, 2.22; 95% confidence interval, 1.09‐4.53; P = .029). However, HAE was not an independent predictor of mortality. Average length of hospital stay was 4 ± 8.5 days after HAE + EVAR vs 3.3 ± 5.9 days after EVAR (P = .001). Conclusions: Concomitant HAE with EVAR is associated with longer and more complicated hospital stays. Ischemic colitis is a rare complication of EVAR. HAE increases the risk of ischemic colitis and renal failure requiring dialysis. This study highlights the importance of hypogastric artery preservation during EVAR.

Functional status predicts major complications and death after endovascular repair of abdominal aortic aneurysms

Objective: Endovascular aneurysm repair (EVAR) is considered a lower risk option for treating abdominal aortic aneurysms and is of particular utility in patients with poor functional status who may be poor candidates for open repair. However, the specific contribution of preoperative functional status to EVAR outcomes remains poorly defined. We hypothesized that impaired functional status, based simply on the ability of patients to perform activities of daily living, is associated with worse outcomes after EVAR. Methods: Patients undergoing nonemergent EVAR for abdominal aortic aneurysm between 2010 and 2014 were identified in the National Surgical Quality Improvement Program (NSQIP) database. The primary outcomes were 30‐day mortality and major operative and systemic complications. Secondary outcomes were inpatient length of stay, need for reoperation, and discharge disposition. Using the NSQIP‐defined preoperative functional status, patients were stratified as independent or dependent (either partial or totally dependent) and compared by univariate and multivariable analyses. Results: Of 13,432 patients undergoing EVAR between 2010 and 2014, 13,043 were independent (97%) and 389 were dependent (3%) before surgery. Dependent patients were older and more frequently minorities; had higher rates of chronic pulmonary, heart, and kidney disease; and were more likely to have an American Society of Anesthesiologists score of 4 or 5. On multivariable analysis, preoperative dependent status was an independent risk factor for operative complications (odds ratio [OR], 3.1; 95% confidence interval [CI], 2.5‐3.9), systemic complications (OR, 2.8; 95% CI, 2.0‐3.9), and 30‐day mortality (OR, 3.4; 95% CI, 2.1‐5.6). Secondary outcomes were worse among dependent patients. Conclusions: Although EVAR is a minimally invasive procedure with substantially less physiologic stress than in open aortic repair, preoperative functional status is a critical determinant of adverse outcomes after EVAR in spite of the minimally invasive nature of the procedure. Functional status, as measured by performance of activities of daily living, can be used as a valuable marker of increased perioperative risk and may identify patients who may benefit from preoperative conditioning and specialized perioperative care.

Emergency department medication history taking: current inefficiency and potential for a self-administered form.

BACKGROUND Emergency Departments (EDs) struggle with obtaining accurate medication information from patients. OBJECTIVE Our aim was to estimate the proportion of urban ED patients who are able to complete a self-administered medication form and record patient observations of the medication information process. METHODS In this cross-sectional study, we consecutively sampled ED patients during various shifts between 8 AM and 10 PM. We created a one-page medication questionnaire that included a list of 49 common medications, categorized by general indications. We asked patients to circle any medications they took and write the names of those not on the form in a dedicated area on the bottom of the page. After their visit, we asked patients to recall which providers had asked them about their medications. RESULTS Research staff approached 354 patients; median age was 45 years (interquartile range 29-53 years). Two hundred and forty-nine (70%) completed a form, 61 (17%) were too ill, 19 (5%) could not read it, and 25 (7%) refused to participate. Excluding refusals, 249 of 329 (76%; 95% confidence interval 70-80%) were able to complete the form. Of 209 patients recalling their visit, 180 (86%) indicated that multiple providers took a history, including 103 in which every provider did so, and 9 (4%) indicated that no provider took a medication history. CONCLUSIONS The process of ED medication information transfer often involves redundant efforts by the health care team. More than 70% of patients presenting for Emergency care were able to complete a self-administered medication information form.

The Evolution of Management Strategies for Blunt Aortic Injury

Blunt traumatic aortic injury is a leading cause of death after blunt trauma. Changes in the treatment of this potentially lethal condition include advances in diagnostic capabilities, with improved CT scanners and the development of improved surgical techniques. A wide spectrum of aortic injury can now be appreciated and such injury stratification identifies patients suitable for medical management alone, delayed surgical repair, or emergent surgical intervention. Finally, the development of endovascular technology has fundamentally changed the surgical repairs that can be successfully utilized in this challenging patient population.

Defining the burden, scope, and future of vascular acute care surgery

Objective The paradigm of acute care surgery has revolutionized nonelective general surgery. Similarly, nonelective vascular surgery may benefit from specific management and resource capabilities. To establish the burden and scope of vascular acute care surgery, we analyzed the characteristics and outcomes of patients hospitalized for vascular surgical procedures in Maryland. Methods A retrospective analysis of a statewide inpatient database was performed to identify patients undergoing noncardiac vascular procedures in Maryland from 2009 to 2013. Patients were stratified by admission acuity as elective, urgent, or emergent, with the last two groups defined as acute. The primary outcome was inpatient mortality, and secondary outcomes were critical care and hospital resource requirements. Groups were compared by univariate analyses, with multivariable analysis of mortality based on acuity level and other potential risk factors for death. Results Of 3,157,499 adult hospital admissions, 154,004 (5%) patients underwent a vascular procedure; most were acute (54% emergent, 13% urgent), whereas 33% were elective. Acute patients had higher rates of critical care morbidity and required more hospital resource utilization. Admission for acute vascular surgery was independently associated with mortality (urgent odds ratio, 2.1; emergent odds ratio, 3.0). Conclusions The majority of inpatient vascular care in Maryland is for acute vascular surgery, which is an independent risk factor for mortality. Acute vascular surgical care entails greater critical care and hospital resource utilization and—similar to emergency general surgery—may benefit from dedicated training and practice models.

Laser Fenestration for Treatment of a Complicated Chronic Type B Aortic Dissection

We report a case of a complex chronic type B aortic dissection treated by thoracic endovascular aortic repair and laser fenestration of the false septum to preserve flow to branch vessels originating from both the true and false lumen. Dissections complicated by thoracoabdominal aneurysmal degeneration with critical organs being perfused by branches arising from both true and false lumens are rare and leave limited options for repair. Despite advancements in endovascular techniques, fenestration remains one of the only means of preserving flow to both the true and false lumens and thus was necessary in the management of our patient. This novel procedure allows complex aortic dissections to be addressed endovascularly, which increases the flexibility and management of this challenging problem that previously required an open repair with significant morbidity.

Endovascular Thrombectomy of Septic Thrombophlebitis of the Inferior Vena Cava: Case Report and Review of the Literature

We describe the cases of 2 patients who had septic thrombophlebitis and were successfully managed with endovascular thrombectomy. Patient A developed septic thrombophlebitis of the inferior vena cava after several retroperitoneal resections for metastatic renal cell carcinoma. The thrombus was successfully removed via endovascular mechanical balloon thrombectomy. Patient B was a patient with pancreatic adenocarcinoma involving the portal vein who developed a septic inferior vena cava thrombus extending from the level and beyond the renal veins, for which she underwent endovascular thrombectomy. We argue that this approach is safe and feasible. It should be considered as a supplemental treatment modality for select decompensating patients who require lifesaving interventions and have contraindications to traditional management of surgical thrombectomy or excision of the involved venous segment.

Blunt multifocal aortic injury with abdominal aortic intimointimal intussusception

Blunt abdominal aortic injury is an infrequent occurrence after blunt trauma. The majority of these injuries result from deceleration forces sustained in motor vehicle collisions. Effects of these forces on the thoracic aorta are well described, but associated spinal compression or distraction can also lead to injury of the affixed abdominal aorta. We present a case of multifocal blunt thoracic and abdominal aortic injury with circumferential abdominal aortic dissection, resulting in aortoaortic intussusception associated with a thoracolumbar spinal injury. The unique diagnostic challenge and subsequent successful endovascular management of a rare nonocclusive abdominal aortic intussusception are herein discussed.