J. Devin B. Watson

Functional Outcome after Resuscitative Endovascular Balloon Occlusion of the Aorta of the Proximal and Distal Thoracic Aorta in a Swine Model of Controlled Hemorrhage

BACKGROUND Noncompressible torso hemorrhage remains an ongoing problem for both military and civilian trauma. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been characterized as a potentially life-saving maneuver. The objective of this study was to determine the functional outcomes, paraplegia rates, and survival of 60-min balloon occlusion in the proximal and distal thoracic aorta in a porcine model of controlled hemorrhage. METHODS Swine (Sus scrofa, 70-110 kg) were subjected to class IV hemorrhagic shock and underwent 60 min of REBOA. Devices were introduced from the left carotid artery and positioned in the thoracic aorta in either the proximal location (pREBOA [n = 8]; just past takeoff of left subclavian artery) or distal location (dREBOA [n = 8]; just above diaphragm). After REBOA, animals were resuscitated with whole blood, crystalloid, and vasopressors before a 4-day postoperative period. End points included evidence of spinal cord ischemia (clinical examination, Tarlov gait score, bowel and bladder dysfunction, and histopathology), gross ischemia-reperfusion injury (clinical examination and histopathology), and mortality. RESULTS The overall mortality was similar between pREBOA and dREBOA groups at 37.5% (n = 3). Spinal cord-related mortality was 12.5% for both pREBOA and dREBOA groups. Spinal cord symptoms without death were present in 12.5% of pREBOA and dREBOA groups. Average gait scores improved throughout the postoperative period. CONCLUSIONS REBOA placement in the proximal or distal thoracic aorta does not alter mortality or paraplegia rates as compared with controlled hemorrhage alone. Functional recovery improves in the presence or the absence of REBOA, although at a slower rate after REBOA as compared with negative controls. Additional research is required to determine the ideal placement of REBOA in an uncontrolled hemorrhage model to achieve use compatible with survival outcomes and quality of life.

Initial management and outcome of modern battlefield anal trauma.

BACKGROUND: Despite the potential for morbidity and permanent lifestyle alteration, few reports exist examining traumatic injury to the anal canal, particularly among modern-day combatants. OBJECTIVE: The aim of this study was to document the incidence, initial surgical management, and long-term outcomes of wartime anal trauma. DESIGN: This study is a retrospective review. DATA SOURCES: Data were compiled from multiple electronic medical record systems, including the Department of Defense Trauma Registry, the Patient Administration Systems and Biostatistics Activity, and the Armed Forces Health Longitudinal Tracking Application. SETTINGS: Combatants were treated at military treatment facilities with surgical capability during the wars in Iraq and Afghanistan, 2003 through early 2011. PATIENTS: All US and coalition combatants sustaining trauma to the anal canal or sphincter musculature were included. MAIN OUTCOME MEASURES: The quantification of incidence, the evaluation of initial treatment approach, and the determination of clinical and surgical factors correlating with restoration or preservation of GI tract continuity were the primary outcomes measured. RESULTS: Anal trauma occurred in 46 combatants, predominantly from blast injury (76.1%). Most (36, 78.2%) underwent fecal diversion. Concurrent severe systemic or intra-abdominal injuries correlated with colostomy creation. Acute anoplasty was attempted in 11 patients (23.7%) but did not influence eventual colostomy reversal. Among 33 US personnel, the permanent colostomy rate was 30.3%. Concurrent injury to the abdomen strongly predicted long-term colostomy (p = 0.009), along with hypogastric arterial ligation (p = 0.05) and pelvic fracture (p = 0.06). LIMITATIONS: This study was limited by the potential underdiagnosis of anal injury and the restricted follow-up of non-US personnel. CONCLUSIONS: Other injuries besides anal trauma typically have guided the decision for fecal diversion, and acute anal repair has rarely been indicated. The majority of patients with anal trauma regained normal GI continuity, although certain pelvic injuries increased the likelihood of permanent colostomy.

Validation of the Short Musculoskeletal Function Assessment in patients with battlefield-related extremity vascular injuries

OBJECTIVE Vascular extremity injuries can be a significant burden on a patients long-term quality of life. Currently, no limb-specific surveys have been used to quantify the relation between injury pattern and the resultant physical or psychological impact. The objective of this study was to validate the use of the Short Musculoskeletal Function Assessment (SMFA) in the setting of extremity vascular injury. METHODS The Joint Theater Trauma Registry was queried and filtered for U.S. troops with an extremity vascular injury isolated to a single limb. Injury and management data were obtained, and the SMFA was administered after patient contact and consent. Validity was analyzed by characterization of SMFA score distribution, correlation with 36-Item Short Form Health Survey (SF-36) scores, and assessment of its discriminative capability to external measures of injury severity (ie, Injury Severity Score [ISS], Mangled Extremity Severity Score [MESS], and Medicare Part A disability qualification). RESULTS At mean follow-up of 5 years, 164 patients (median age, 25 years; interquartile range, 22-31 years) completed both surveys. The overall SMFA Dysfunction Index was 24.8 ± 15.2 (range, 0-78; skewness, 0.60; floor/ceiling effect, 0%-1.2%; and nonresponse, 0%), and the overall Bother Index was 29.4 ± 20.2 (range, 0-96; skewness, 0.58; floor/ceiling effect, 0%-4.3%; and nonresponse, 0.6%). SF-36 physical component summary scores correlated inversely with the Dysfunction Index (r = -0.64; P < .01), whereas mental component summary scores correlated inversely with the Bother Index (r = -0.59; P < .01). No difference was found in reported scores between those considered severely injured (ISS > 15) and those not severely injured (ISS ≤ 15). However, those with mangled extremities (MESS ≥ 7) reported higher Dysfunction and Bother indices than those with lower scores (P < .05). In addition, patients considered disabled (per Medicare Part A qualifications) reported higher Dysfunction and Bother indices compared with those not considered disabled (P < .05). CONCLUSIONS Use of the SMFA is validated in those with extremity vascular injuries, and it should be considered an adjunctive tool in evaluating long-term patient outcomes.

Biochemical markers of acute limb ischemia, rhabdomyolysis, and impact on limb salvage

Biochemical markers of ischemia reperfusion injury have been of interest to vascular surgeons and researchers for many years. Acute limb ischemia is the quintessential clinical scenario where these markers would seem relevant. The use of biomarkers to preoperatively or perioperatively predict which patients will not tolerate limb-salvage efforts or who will have poor functional outcomes after salvage is of immense interest. Creatinine phosphokinase, myoglobin, lactate, lactate dehydrogenase, potassium, bicarbonate, and neutrophil/leukocyte ratios are a few of the studied biomarkers available. Currently, the most well-studied aspect of ischemia reperfusion injury is rhabdomyolysis leading to acute kidney injury. The last 10 years have seen significant progression and improvement in the treatment of rhabdomyolysis, from minor supportive care to use of continuous renal replacement therapy. Identification of specific biomarkers with predictive outcome characteristics in the setting of ischemia reperfusion injury will help guide therapeutic development and potentially mitigate pathophysiologic changes in acute limb ischemia, including rhabdomyolysis. These may further lead to improvements in short- and long-term surgical outcomes and limb salvage, as well as a better understanding of the timing and selection of intervention.

Combined Arteriovenous Thrombolytic Infusion for Refractory Renal Vein Thrombosis

Acute renal vein thrombosis can rapidly lead to significant impairment and eventual loss of renal function. Classically presenting with flank pain, hematuria, and laboratory markers consistent with acute kidney injury, therapeutic anticoagulation is the mainstay of treatment. However, endovascular surgery offers a safe and effective alternative for renal salvage in the setting of acute renal vein thrombosis. Described is the use of combined arteriovenous thrombolytic infusion for refractory renal vein thromboses to quickly and effectively decrease clot burden in the micro- and macrovenous circulations while limiting systemic exposure.