Tze-Woei Tan

Early fasciotomy in patients with extremity vascular injury is associated with decreased risk of adverse limb outcomes: A review of the National Trauma Data Bank

INTRODUCTION AND OBJECTIVES Lower extremity (LE) arterial trauma and its treatment may lead to extremity compartment syndrome (ECS). In that setting, the decision to perform fasciotomies is multifactoral and is not well delineated. We evaluated the outcomes of patients with surgically treated LE arterial injury who underwent early or delayed fasciotomies. METHODS The National Trauma Data Bank (NTDB) was retrospectively reviewed for patients who had LE arterial trauma and underwent both open vascular repair and fasciotomies. Exclusion criteria were additional non-LE vascular trauma, head or spinal cord injuries, crush injuries, burn injuries, and declaration of death on arrival. Patients were divided into those who had fasciotomies performed within 8h (early group) or >8h after open vascular repair (late group). Comparative analyses of demographics, injury characteristics, complications, and outcomes were performed. RESULTS Of the 1469 patient admissions with lower extremity arterial trauma that met inclusion criteria there were 612 patients (41.7%) who underwent fasciotomies. There were 543 and 69 patients in the early and late fasciotomy groups, respectively. There was no significant difference in age, injury severity, mechanism of injury, associated injuries, and type of vascular repair between the groups. A higher rate of iliac artery injury was observed in the late fasciotomy group (23.2% vs. 5.9%, P<.001). Patients in the early fasciotomy group had lower amputation rate (8.5% vs. 24.6%, P<.001), lower infection rate (6.6% vs. 14.5%, P = .028) and shorter total hospital stay (18.5 ± 20.7 days vs. 24.2 ± 14.7 days, P = .007) than those in the late fasciotomy group. On multivariable analysis, early fasciotomy was associated with a 4-fold lower risk of amputation (Odds Ratio 0.26, 95% CI 0.14-0.50, P<.0001) and 23% shorter hospital LOS (Means Ratio 0.77, 95% CI 0.64-0.94, P = .01). CONCLUSION Early fasciotomy is associated with improved outcomes in patients with lower extremity vascular trauma treated with surgical intervention. Our findings suggest that appropriate implementation of early fasciotomy may reduce amputation rates in extremity arterial injury.

Predictors of shunt during carotid endarterectomy with routine electroencephalography monitoring

BACKGROUND The routine use of intraoperative electroencephalography (EEG) monitoring with selective shunt placement during carotid endarterectomy (CEA) has been shown to be safe and effective. We attempt to identify the anatomic and clinical factors associated with significant EEG changes requiring shunt placement during CEA. METHODS Between January 2005 and June 2007, 242 CEAs were performed with selective shunt placement for significant EEG changes. Risk factors assessed include severity of both ipsilateral and contralateral disease, presence of ipsilateral preoperative symptoms, hypertension, coronary artery disease, diabetes, age, gender, and preemptive intraoperative blood pressure manipulation to >or=20% above baseline before cross-clamping. Data were analyzed with the chi(2) test (P < .05 was significant). RESULTS CEA was performed for asymptomatic disease in 177 of 242 patients (73.1%). The perioperative stroke rate was 0.8% (2 of 242), and the overall morbidity rate was 4.5%. No patients died. Significant EEG changes requiring shunt occurred in 35 patients (14.46%). Factors associated with carotid shunt placement were moderate ipsilateral carotid artery stenosis (50% to 79%) compared with severe (>or=80%) disease (30.6% vs 11.7%, P = .003) and degree of contralateral carotid stenosis (0% to 49%, 10.8%; 50% to 79%, 10.9%; 80% to 99%, 23.2%; occlusion, 50%; P = .0003). Presence of symptoms, gender, age, hypertension, diabetes, or coronary artery disease, and preemptive intraoperative manipulation of blood pressure were not significant predictors of shunt placement. CONCLUSION CEA performed with routine EEG monitoring and selective shunt placement is associated with a low risk of perioperative stroke. Identified predictors of significant EEG changes were anatomic factors including degree of contralateral carotid artery disease and moderate ipsilateral carotid artery stenosis (50% to 79%). Although contralateral carotid occlusion has been accepted as indication for shunt placement in the absence of cerebral monitoring, this study suggests that high-grade contralateral disease and moderate ipsilateral carotid stenosis are associated with cerebral ischemia resulting in EEG changes and should prompt consideration for nonselective shunting.

Blood Transfusion for Lower Extremity Bypass Is Associated with Increased Wound Infection and Graft Thrombosis

BACKGROUND Packed RBC transfusion has been postulated to increase morbidity and mortality after cardiac/general surgical operations, but its effects after lower extremity bypass (LEB) have not been studied extensively. STUDY DESIGN Using the Vascular Study Group of New Englands database (2003-2010), we examined 1,880 consecutive infrainguinal LEB performed for critical limb ischemia. Perioperative transfusion was categorized as 0 U, 1 to 2 U, and ≥3 U. Cohort frequency group matching was used to compare groups of patients receiving 1 to 2 U and 0 U with patients receiving ≥3 U using age, coronary artery disease, diabetes, urgency, and indication of revascularization. Primary end points were perioperative mortality, wound infection, and loss of primary graft patency at discharge, as well as 1-year mortality and loss of primary graft patency. RESULTS In the study cohort, 1,532 LEBs (81.5%) received 0 U, 248 LEBs (13.2%) received 1 to 2 U, and 100 LEBs (5.3%) received ≥3 U transfusion. In the study cohort and group frequency matched cohort, transfusion was associated with significantly higher perioperative wound infection (0 U:4.8% vs 1 to 2 U: 6.5% vs ≥3 U: 14.0%; p = 0.0004) and graft thrombosis at discharge (4.5% vs 7.7% vs 15.3%; p < 0.0001). At 1 year, there were no differences in infection or graft patency. In multivariate analysis, transfusion was independently associated with increased perioperative wound infection in the study cohort and group frequency matched cohort (1 to 2 U vs 0 U: adjusted odds ratio [OR] = 1.4; 95% CI, 0.8-2.5; p = 0.263; ≥3 U vs 0 U: OR = 3.5; 95% CI, 1.8-6.7; p = 0.0002; overall p = 0.002) and increased graft thrombosis at discharge (1 to 2 U vs 0 U: OR = 2.1; 95% CI, 1.2-3.6; p = 0.01; ≥3 U vs 0 U: OR = 4.8; 95% CI, 2.5-9.2; p < 0.0001, overall p < 0.0001). CONCLUSIONS Perioperative transfusion in patients undergoing LEB is associated with increased perioperative wound infection and graft thrombosis. From this observational study, it appears transfusion does not have major consequences during mid-term follow-up, but the presumed benefits of blood replacement should be weighed carefully because of the increased risk of perioperative complications with transfusion.

Limb Outcome and Mortality in Lower and Upper Extremity Arterial Injury A Comparison Using the National Trauma Data Bank

Objective: To examine the outcomes of lower extremity (LE) and upper extremity (UE) arterial trauma. Methods: Retrospective review of 2008 version of National Trauma Databank. Adult patient with LE and UE arterial trauma was identified and outcomes were compared. Results: There were 8311 cases of extremity arterial trauma and 37% involved the LE. The LE cohort had higher blunt injury (56.2% vs 37.4%; P < .0001). The LE cohort was more likely to require fasciotomy (23.6% vs 6.7%; P < .0001) and amputation (7.8% vs 1.3%; P < .0001). Complication (18.8% vs 5.1%; P < .0001) and mortality rate (7.7% vs 2.2%, P < .0001) were higher in the LE cohort. Regardless of extremity, blunt trauma was associated with higher mortality (4.8% vs 3.8%; P = .03) and amputation (6.7% vs 1.3%; P < .0001). In multivariable analysis, LE arterial trauma was associated with increased mortality (odds ratio [OR] 2.2, 95% confidence interval [CI] 1.7-2.9; P < .0001) and amputation (OR 4.3, 95% CI 3.2-5.8; P < .0001). Conclusions: Lower and upper extremity arterial injuries have different modes of presentation and outcomes. Lower extremity arterial trauma is more commonly caused by blunt injury and associated with worse outcomes despite more intensive intervention.

The need for treatment of hemodynamic instability following carotid endarterectomy is associated with increased perioperative and 1-year morbidity and mortality

OBJECTIVE The objective of this study was to evaluate the outcomes of patients after carotid endarterectomy (CEA) who developed postoperative hypertension or hypotension requiring the administration of intravenous vasoactive medication (IVMED). METHODS We examined consecutive, primary elective CEA performed by 128 surgeons within the Vascular Study Group of New England (VSGNE) database (2003-2010) and compared outcomes of patients who required postoperative IVMED to treat hyper- or hypotension with those who did not. Outcomes included perioperative death, stroke, myocardial infarction (MI), congestive heart failure (CHF), hospital length of stay, and 1-year stroke or death. Propensity score matching was performed to facilitate risk-adjusted comparisons. Multivariable regression models were used to compare the association between IVMED and outcomes in unmatched and matched samples. Factors associated with use of IVMED in postoperative hypertension and hypotension were evaluated, and predictive performance of multivariable models was examined using receiver operating characteristic (ROC) curves. RESULTS Of 7677 elective CEAs identified, 23% received IVMED for treatment of either postoperative hypertension (11%) or hypotension (12%). Preoperative neurological symptomatic status (20%) was similar across cohorts. In the crude sample, the use of IVMED to treat postoperative hypertension was associated with increased 30-day mortality (0.7% vs 0.1%; P < .001), stroke (1.9% vs 1%; P = .018), MI (2.4% vs 0.5%; P < .001), and CHF (1.9% vs 0.5%; P < .001). The use of IVMED to treat postoperative hypotension was also associated with increased perioperative mortality (0.8% vs 0.1%; P < .001), stroke (3.2% vs 1.0%; P < .001), MI (2.7% vs 0.5%; P < .001), and CHF (1.7% vs 0.5%; P < .001), as well as 1-year death (5.1% vs 2.9%; P < .001) or stroke (4.2% vs 2.1%; P < .001). Hospital length of stay was significantly longer among patients who needed IVMED for postoperative hypertension (2.8 ± 4.7 days vs 1.7 ± 5.5 days; P < .001) and hypotension (2.8 ± 5.9 days vs 1.7 ± 5.5 days; P < .001). In multivariable analysis, IVMED for postoperative hypertension was associated with increased MI, stroke, or death (odds ratio, 2.6; 95% confidence interval [CI], 1.6-4.1; P < .001). Similarly, IVMED for postoperative hypotension was associated with increased MI, stroke, or death (odds ratio, 3.2; 95% CI, 2.1-5.0; P < .001), as well as increased 1-year stroke or death (hazard ratio, 1.6; 95% CI, 1.2-2.2; P = .003). Smoking, coronary artery disease, and clopidogrel (ROC, 0.59) were associated with postoperative hypertension requiring IVMED, whereas conventional endarterectomy and general anesthesia were associated with postoperative hypotension requiring IVMED (ROC, 0.58). The unitization of IVMED varied between 11% and 38% across VSGNE, and center effect did not affect outcomes. CONCLUSIONS Postoperative hypertension requiring IVMED after CEA is associated with increased perioperative mortality, stroke, and cardiac complications, whereas significant postoperative hypotension is associated with increased perioperative mortality, cardiac, or stroke complications, as well as increased 1-year death or stroke following CEA. The utilization of IVMED varied across centers and, as such, further investigation into this practice needs to occur in order to improve outcomes of these at-risk patients.

Delayed Presentation of a Brachial Artery Pseudoaneurysm After a Supracondylar Humerus Fracture in a 6-year-old Boy: A Case Report

Supracondylar fractures of the humerus are the most common elbow fractures in children, accounting for 60% to 70% of all pediatric elbow fractures. These fractures often have neurovascular complications because of deformity and the sharp nature of the fracture fragments. The management of patients who present with diminished or absent pulses, but a well-perfused extremity is a topic of debate. Between 3% and 14% of patients present with an altered vascular examination and a consistent treatment logarithm has not been proposed in the literature. To our knowledge, a brachial artery pseudoaneurysm presenting in a delayed fashion in the setting of a normal vascular examination has not been reported. We report a 6-year-old boy who had a delayed presentation of a brachial artery pseudoaneurysm after a supracondylar humerus fracture, which was repaired with a saphenous vein graft. This is to emphasize close neurological and vascular monitoring even in the setting of a well-perfused hand. In addition, this would suggest that closer postoperative evaluation in significantly displaced fractures should be performed, even beyond the fracture healing stage.

Blood transfusion is associated with increased risk of perioperative complications and prolonged hospital duration of stay among patients undergoing amputation

OBJECTIVE We evaluated the outcomes of patients undergoing major lower-extremity amputation who received packed red blood cell transfusion. METHODS Using the dataset of the National Surgical Quality Improvement Program (2005-2011), we examined 5,739 above-knee and 6,725 below-knee amputations. Patients were stratified by perioperative (preoperative, intraoperative, or postoperative) blood transfusion. Outcomes included perioperative mortality, myocardial infarction (MI), thromboembolism, and duration of stay (DOS) at the hospital. Adjusted comparisons of outcomes between transfused and not-transfused patients were performed by matching the 2 groups for age, smoking, diabetes, renal failure, coronary artery disease, classification of the American Society of Anesthesiologists, functional status, and procedure type. Multivariable logistic and gamma regression were used to examine associations between transfusion and outcomes. RESULTS Of the 12,464 amputations in the study cohort 2,133 (17%) required transfusion. The majority of the cases were performed for critical limb ischemia (8,205 amputations; 66%) and the overall 30-days mortality was 9%. In both crude and matched cohorts, although perioperative mortality and cardiac complication rates were similar, transfusion was associated with a greater incidence of pneumonia (crude: 6.1% vs 3%, P < .001; matched: 5.9% vs 3.7%, P < .001), thromboembolism (2.5% vs 1.6%, P = .003; 2.5% vs 1.4%, P = .002) and longer DOS (18 ± 19 vs 13.6 ± 14.3 days, P < .001; 17.8 ± 18.4 vs 14.2 ± 14.5 days, P < .001). Multivariable adjustment for confounding variables in the crude cohort demonstrated that transfusion was independently associated with a greater odds of perioperative pneumonia (odds ratio [OR]:1.6; 95% confidence interval [CI]:1.3-2; P < .001), thromboembolism (OR 1.3, 95% CI 1.0-1.9, P = .09) and longer DOS (mean ratio: 1.1; 95% CI 1.1-1.6; P = .006). CONCLUSION Among patients who had major lower-extremity amputation, perioperative transfusion independently predicted greater risks for perioperative pneumonia, thromboembolism, and prolonged hospital DOS.

Endovascular Revascularization of Symptomatic Infrapopliteal Arteriosclerotic Occlusive Disease: Comparison of Atherectomy and Angioplasty

The preferred method for revascularization of symptomatic infrapopliteal arterial occlusive disease (IPAD) has traditionally been open vascular bypass. Endovascular techniques have been increasingly applied to treat tibial disease with mixed results. We evaluated the short-term outcome of percutaneous infrapopliteal intervention and compared the different techniques used. A retrospective analysis of consecutive patients undergoing endovascular treatment for infrapopliteal arterial occlusive lesions between 2003 and 2007 in a tertiary teaching hospital was performed. Patient demographic data, indication for intervention, and periprocedural complications were recorded. Periprocedural and short-term outcomes were measured and compared. Forty-nine infrapopliteal arteries in 35 patients were treated. Twenty vessels (15 patients) underwent angioplasty and 29 vessels (20 patients) were treated with atherectomy. Demographic and angiographic characteristics were similar between the groups. Twenty-six patients had concurrent femoral and/or popliteal artery interventions. Overall, technical success was 90% and similar between angioplasty and atherectomy groups (85% versus 93%, p = NS). The vessel-specific complication rate was 10% and was similar between both groups (angioplasty 5% versus atherectomy 14%, p = NS). One dissection occurred in the angioplasty group; one perforation and three thromboembolic events occurred in the atherectomy group. Limb salvage and freedom from reintervention at 6 months were 81% and 68%, respectively, and were not significantly different between the angioplasty and atherectomy groups. Endovascular intervention for IPAD had acceptable periprocedural and short-term success rates in our high-risk patient population. Both atherectomy and angioplasty can be used successfully to treat symptomatic IPAD.

Brachial-Basilic Autogenous Access

The emphasis on autogenous arteriovenous hemodialysis access has increased the focus on the brachial-basilic autogenous configuration currently recommended by the national guidelines when the cephalic vein is not suitable. The brachial-basilic autogenous access has been extensively studied and compared with both prosthetic (arteriovenous graft [AVG]) and other autogenous accesses. The literature suggests that the brachial-basilic autogenous access is superior to AVGs in terms of patency, reintervention rates, and infectious complications. However, controversy still remains with respect to its role in the treatment algorithm and the technical conduct of the operation. This review will address the ongoing issues and controversies surrounding the brachial-basilic autogenous access and define its role for the hemodialysis access surgeon.

Percutaneous Endovascular Repair of Abdominal Aortic Aneurysm with Coexisting Horseshoe Kidney: Technical Aspects and Review of the Literature

Surgical repair of abdominal aortic aneurysms (AAAs) with coexisting horseshoe kidney (HSK) is technically challenging because of complex anatomy. Endovascular repair has emerged as a common approach to AAA repair and represents a valid alternative in selected patients with AAA and concomitant congenital renal anomalies. We report a case of successful percutaneous endovascular repair in a patient with coexistent AAA and HSK. Careful preoperative planning is essential in successful endovascular management of abdominal aneurysms in these patients.