Mark R. Sarfati

National trauma databank analysis of mortality and limb loss in isolated lower extremity vascular trauma.

OBJECTIVES Lower extremity injury is common in trauma patients; however, the influence of arterial injury on devastating patient and limb outcomes can be confounded by the presence and physiological derangement of concomitant head or thoracoabdominal injuries. We analyzed isolated lower extremity injuries with an arterial component. Our aim was to elucidate factors associated with mortality and limb loss in this selected population. METHODS We reviewed trauma incidents from the National Trauma Data Bank (2002-2006) containing isolated lower extremity injury codes and a specified infrainguinal arterial injury. Demographics, injury patterns, clinical characteristics, and adverse outcomes (death, amputation) during initial hospitalization were collected. Multivariate logistic regression was used to identify risk factors for limb loss. RESULTS There were 651 isolated infrainguinal arterial injuries. Death (18) and early limb loss (42) were studied by mechanism (penetrating, n = 431; blunt, n = 220). Half of the deaths involved injury to the common femoral artery (CFA), and over 80% had injury to the CFA or superficial femoral artery (SFA). Death was three times as frequent in the CFA/SFA than in the popliteal/tibial injuries (P = .02). Penetrating injuries were present in almost 80% of deaths, and most of these were gunshot wounds. Patients who died had mean initial systolic blood pressure of 59.7 mm Hg, and almost 40% had no blood pressure on arrival. Mean initial Glasgow Coma Score was 4.5, and almost 80% arrived with a Glasgow Coma Score of 3 despite the absence of head injury. Twenty-seven above- and 15 below-the-knee amputations were performed. The popliteal artery was injured in half of the amputations, with injury isolated to the popliteal or tibial arteries in about three-quarters. Amputation was twice as frequent in popliteal/tibial than CFA/SFA injury (P = .03) and twice as frequent in blunt than penetrating injury (P = .05). Multiple arterial injuries (odds ratio, 5.2; 95% confidence interval, 1.7-15.6; P = .003), and fracture (odds ratio, 2.2; 95% confidence interval, 1.1-4.2; P = .02) independently predicted amputation, while the presence of nerve injury and soft tissue disruption did not. CONCLUSIONS Isolated lower extremity trauma with vascular injury has a nearly 10% rate of mortality or limb loss. Mortality is associated with penetrating mechanism and early shock, likely resulting from prehospital proximal arterial hemorrhage. In contrast, early limb loss is more common with blunt distal vascular injury, especially to the popliteal and tibial arteries. Neither nerve nor soft tissue injury predicted limb loss but may result in delayed amputations not captured in this acute outcomes dataset.

Intraoperative blood product resuscitation and mortality in ruptured abdominal aortic aneurysm

OBJECTIVES The resuscitation of patients with ruptured abdominal aortic aneurysms (RAAAs) has not been well studied, and the potential benefit of autotransfusion (AT) is unknown. The increased use of fresh-frozen plasma (FFP) has been associated with decreased mortality rates in trauma patients and may also improve RAAA survival. We explored the influence of intraoperative AT and FFP resuscitation on mortality rates in massively transfused RAAA patients. METHODS A single-center review of RAAA patient records from April 1989 to October 2009 was undertaken. Clinical data and outcomes were studied. Operative and anesthesia records were queried for intraoperative transfusion totals. Massive transfusion was defined as ≥10 units of red blood cells (RBCs) inclusive of AT units. RESULTS We identified 151 RAAA patients, of which 89 (60%) received a massive transfusion and comprised the study population. These 89 patients had an in-hospital mortality rate of 44%. Univariate predictors of mortality included increased age, preoperative hypotension, operative blood loss, and crystalloid, RBCs, and FFP volume. AT was used in 85 patients, with an increased ratio of AT:RBC units associated with survival. Mortality was 34% with AT:packed RBCs (PRBC) ≥1 (high AT) and 55% with AT:PRBC of <1 (low AT; P = .04). On multivariate analysis, age > 74 years (P = .03), lowest preoperative systolic blood pressure (SBP) <90 mm Hg (P = .06), blood loss >6 liters (P = .06), and low AT (P = .02) independently predicted mortality. The mean RBC:FFP ratio was similar in those that died (2.7) and in those that lived (2.9; P = .66). RBC:FFP ≤2 (high FFP) was present in 38 (43%) patients, with mortality of 49%. RBC:FFP >2 (low FFP) had 40% mortality (P = .39). RBC:FFP ratios decreased over time from 3.6 (years 1989 to 1999) to 2.2 (years 2000 to 2009; P < .001), but more liberal use of FFP was not associated with decreased mortality (47% vs 41%; P = .56). AT:PRBC ratios were stable over time (range, 1.4-1.2; P = .18). CONCLUSIONS Greater use of AT but not of FFP was associated with survival in massively transfused RAAA patients. No mortality benefit was seen with increased FFP, but few patients had high FFP transfusion ratios. Further study to identify RAAA patients at risk for massive transfusion should be undertaken and a potentially greater role for AT in RAAA resuscitation investigated.

Embolic atrial myxoma causing aortic and carotid occlusion.

BACKGROUND Cardiac myxomas are a rare but well-described cause of stroke that usually occur in young people. Cardiac myxoma can embolize to multiple sites throughout the body. CASE DESCRIPTION A 45-year-old woman presented acutely with altered mental status and signs of lower extremity vascular occlusion. Pathologic studies confirmed the diagnosis of cardiac myxoma. CONCLUSIONS This is the first case reported in the English literature of simultaneous aortic and internal carotid artery occlusion from embolism of an atrial myxoma without evidence of intracardiac tumor on transesophageal echocardiogram.

Has the changing nature of vascular surgery adversely affected scholarly activity

OBJECTIVE Because of reduced reimbursement and introduction of endovascular techniques into practice, vascular surgeons have increased clinical commitments. Therefore we hypothesized that the scholarly productivity of vascular surgeons has decreased. Study design An author-based Medline search was carried out for members of the Society for Vascular Surgery (SVS). The search included the period from 1985 to 1989 (era 1) for members in 1990, and from 1995 to 1999 (era 2) for members in 2000. Citations were assigned a type: basic science, clinical, case report, letter, or other; and a topic: cardiac, vascular, endovascular, transplantation, or miscellaneous. The main outcome measures were the proportion of members who published in each era and the rates of publication among authors. RESULTS For era 1, 7069 citations were identified for 529 members, and for era 2, 6823 citations were identified for 615 members. Four hundred forty-two members were cited in era 1 (84%), compared with 443 (72%) in era 2 (P =.01). A significantly smaller proportion of members published clinical research, case reports, and other publications, but not basic science or letters. Excluding unpublished members, there was a median of 11 total publications per author in each era. There were significant reductions in the proportion of members publishing papers related to cardiac (from 36% to 21%), transplantation (8% to 4%), and miscellaneous (43% to 31%) topics, and a significant increase in papers related to endovascular topics (from 19% to 28%) from era 1 to era 2. Moreover, there was a significant increase in median number of vascular (from 5 to 8) and endovascular (1 to 2) papers per published member. Further, the proportion of vascular and endovascular citations compared with total citations increased from 44% to 56% in era 1 and from 3% to 10% in era 2. On a yearly basis, there was a steady decrease in the number of citations throughout era 2, whereas the number of citations in era 1 was relatively constant. CONCLUSIONS Academic productivity was maintained for individual members who published across both eras, but a smaller proportion of the SVS membership published in era 2. There was also a progressive reduction in the number of publications during the 1990s.

A design modification to minimize tilting of an inferior vena cava filter does not deliver a clinical benefit.

OBJECTIVE In July 2007, our group began to use a modified conical inferior vena cava filter with additional stabilizing struts designed to reduce tilting of retrievable filters. We analyzed our experience with this modified filter (Cook Medical, Bloomington, Ind) from July 1, 2007 to December 31, 2008 and compared it to our experience with the standard filter (Günther Tulip, Cook Medical, Bloomington, Ind) from January 1, 2006 through December 31, 2008 to determine if adoption of the modified filter reduced tilting and delivered a discernible clinical benefit. METHODS The primary outcome measure was tilt angle after deployment. Secondary outcomes were change in tilt angle between deployment and retrieval (self-centering) and retrieval failure due to inability to engage the filter hook. Measurements were retrospectively determined using the anteroposterior venogram at the time of placement and removal. Tilt angle was defined by the center line of the filter relative to the center line of the inferior vena cava (IVC). Statistical significance was assumed for P ≤ .05. RESULTS During the study period, a total of 302 IVC filters were placed. Retrieval was attempted for 85 of 194 (44%) standard filters and 52 of 108 (48%) modified filters. The overall difference in tilt angle (degrees) between the standard (median [interquartile range] = 5 [3, 8]) and modified (5 [3, 8]) filters at the time of placement was not statistically significant (P = .44). Modified filters deployed through a femoral route (8 [4, 11]) had significantly greater tilt angles than modified filters deployed using jugular access (4 [2, 6]; P < .0001). At the time of retrieval, evidence of self-centering was observed more often with modified (32 of 52 [62%]) than standard (36 of 85 [42%]) filters (P = .03). Overall, there were only four failures to retrieve the filter due to excess tilting (standard, 3 of 85 [4%], modified, 1 of 52 [2%]; P = .59). CONCLUSION Overall, tilt angle at insertion did not differ between the modified and standard filters, although more modified filters displayed self-centering. There was no difference between the groups in retrieval failure due to excess tilting. Despite its greater tendency to self-center, we did not recognize a measurable clinical advantage of the modified filter.

DELAYED ABDOMINAL CLOSURE IN THE MANAGEMENT OF RUPTURED ABDOMINAL AORTIC ANEURYSM.: 144-S

The objective of this study was to compare initial use of the open abdomen using the vacuum-pack technique followed by delayed abdominal closure with standard primary abdominal closure in the treatment of ruptured abdominal aortic aneurysm (rAAA) repair. A retrospective review identified 122 rAAA cases, which were divided into two management eras: era 1 (primarily closed) and era 2 (47% open abdomen).One hundred three patients were included in this review: 58 in era 1 and 45 in era 2. Evidence of one of three ischemia-reperfusion (IR) criteria, preoperative hypotension, estimated blood loss > or = 6 L, or intraoperative resuscitation with > or = 12 L, predicted mortality. These criteria were also used as surrogate clinical markers for abdominal compartment syndrome. The in-hospital mortality was higher in those with at least one IR criterion: 43% versus 10% (p = .0003). In those with at least one IR criterion, the initial 24-hour mortality was 21% for era 1 versus 0% for era 2 (p = .03), and the 30-day mortality was 40% for era 1 and 32% for era 2 (p = .77).Three IR criteria were identified and were associated with increased mortality. Patients with these risk factors who were treated with delayed abdominal closure had an improved acute survival rate and a trend for improved long-term survival.

PC092. Patient-Reported Outcomes in Patients With End-Stage Renal Disease: Is Quality of Life Affected When Catheters Are Used for Hemodialysis versus Arteriovenous Fistulas?

FA access was performed in three arteries because of prior common FA interposition grafts. There were 18 (6%) access site complications (8 bleeding, 9 thrombosis, 1 infection) leading to immediate (n 1⁄4 12) or delayed (n 1⁄4 5) conversion to cutdown. Factors independently associated with percutaneous access site complication were sheath outer diameter to FA diameter ratio (odds ratio [OR], 58.9; 95% confidence interval [CI], 3.5-985.8; P 1⁄4 .005), morbid obesity with a body mass index of >40 kg/ m (OR, 16.0; 95% CI, 3.0-84.5; P 1⁄4 .001), FA stenosis of >50% (OR, 52.1; 95% CI, 7.7-351.5; P # . 001), FA stenosis of >75% (OR, 271.5; 95% CI, 15.14888.6; P # .001), and postoperative anticoagulation (OR, 10.5; 95% CI, 2.0-54.0; P 1⁄4 .005). A risk prediction model based on these criteria produced a C statistic of .91, a Hosmer-Lemeshow goodness of fit of 0.99, and a Brier score of .03. A risk score of >6 of 15 corresponded with a >10% probability of groin access complication (Table). Conclusions: Percutaneous ultrasound-guided access can be safely performed in almost all patients undergoing endovascular aortic procedures; however, access site failures still occur. Application of this risk score can help identify patients at high risk for complications after initial FA ultrasound-guided percutaneous access.