Xingjiang Wu

Temporary intravascular shunts used as a damage control surgery adjunct in complex vascular Injury: Collective review

In this systemic review, we summarise the types, configurations, durations, indications and complications of the temporary intravascular shunts used as an adjunct of damage control surgery (DCS) in severe vascular injuries. We conclude that temporary intravascular shunts can be used without systemic anticoagulation for a prolonged time to maintain distal perfusion in combined orthopaedic and vascular injuries, in the setting of DCS and transferring.

Multidisciplinary Stepwise Management Strategy for Acute Superior Mesenteric Venous Thrombosis: An Intestinal Stroke Center Experience

BACKGROUD Acute superior mesenteric venous thrombosis (ASMVT) is an uncommon but catastrophic abdominal vascular emergency with high rate of intestinal failure and mortality. The retrospective pilot study was performed to assess the effect of a multidisciplinary stepwise management strategy on survival and mesenteric recanalization in an integrated intestinal stroke center (ISC). MATERIALS AND METHODS A modern management strategy performed by multidisciplinary specialists in ISC was evaluated among 43 ASMVT patients that were classified into central vs peripheral type, operative vs nonoperative, early vs late treated group from March 2009 to April 2013. Patients received specific medical therapy, endovascular treatment, damage-control surgery, selective second-look laparotomy, critical care management, and clinical nutrition support in a stepwise way. The demographics, etiology, imaging characteristics, treatment procedures, complications, clinical outcome, and 1-year follow-up data were analyzed and compared. Confounding factors of mortality were identified by univariate and ROC-curve analysis. A single-center experience of over 5years for this modern strategy was also reported. RESULTS The protocol of multidisciplinary stepwise management strategy was followed in all ASMVT patients successfully. The 30-day mortality and recanalization rate were 11.63% and 90.70%. Initial damage-control surgery was carried out in 46.51% patients, with selective second-look laparotomy in 23.26% patients. Endovascular thrombolysis was performed in 83.72% patients initially or postoperatively. Bowel resection was necessary in 18 patients with the length of 100.00 (47.50, 222.50) cm. The incidence of short-bowel syndrome was 13.95%. The rate and length of bowel resection, short-bowel syndrome rate were significantly lower in nonoperative and early-treated groups (P<0.05). During the follow-up survey, 1-year survival was 83.72%, with no additional death or re-thrombosis. CONCLUSION A multidisciplinary stepwise management strategy involving modern surgical and endovascular treatments that focus on early mesenteric recanalization and bowel viability salvage in a specialized ISC could significantly improve the clinical outcome of ASMVT patients.

Comparison study of Doppler ultrasound surveillance of expanded polytetrafluoroethylene-covered stent versus bare stent in transjugular intrahepatic portosystemic shunt

This prospectively randomized controlled study aimed to assess with Doppler ultrasound (US) the shunt function of expanded polytetrafluoroethylene (ePTFE)‐covered transjugular intrahepatic portosystemic shunt (TIPS) stent versus bare stent and to evaluate the usefulness of routine TIPS follow‐up of ePTFE‐covered stents.

Prolonged indwelling time of temporary vascular shunts is associated with increased endothelial injury in the porcine mesenteric artery.

BACKGROUND Temporary intravascular shunts (TIVS) have been used as a damage control surgery (DCS) adjuncts in superior mesenteric artery (SMA) injuries, both experimentally and clinically. However, no study to date has evaluated the relationship between shunt indwelling time and resultant endothelial cell (EC) injury. We hypothesized that prolonged use of TIVS in SMA injuries would jeopardize EC integrity. METHOD After laparotomy, the SMA was clamped and transected while pigs were hemorrhaged to 40 mm Hg for 30 minutes. A TIVS was inserted between transected ends of the SMA without systemic anticoagulation. Totally, 24 animals were resuscitated and randomized to different shunt indwelling time groups: A, 3 hours; B, 6 hours; C, 9 hours; and D, 12 hours. Patency of shunts was monitored and recorded. Continuous wave Doppler was used as a determinant of adequacy of flow through the shunts. Transmural SMA biopsies from areas of TIVS placement were examined with electron microscopy for histopathologic injury after staining with hematoxylin and eosin and immunofluorescence using a validated histopathologic injury score (minimum-maximum score: 0-4). RESULTS Severity of endothelial injury was observed to be directly related to shunt indwell time. SMA transmural biopsies harvested from group D animals showed the most profound injury, demonstrating extensive EC denudations and marked intimal rupture (injury grade, 3.4 ± 0.2). Sections from group A animals revealed the mildest EC injury (1.3 ± 0.3 vs. group D p < 0.01). No significant difference was detected between group A and B. EC injury grade in group C (2.7 ± 0.6) was higher than that in group B (1.8 ± 0.6) but did not reach statistical significance (p = 0.58). CONCLUSION When possible, vascular reconstruction following use of shunts should include an interposition graft after debridement of the arterial edges having interfaced with the shunt. Finally, to minimize intimal injury to the native vessel, this model suggests that indwell times of shunts should be <9 hours.

Transcatheter thrombolysis centered stepwise management strategy for acute superior mesenteric venous thrombosis

Acute superior mesenteric venous thrombosis (ASMVT) is a rare but potentially lethal abdominal calamity. Outcome depends on prompt recognition and revascularization before progresses to bowel gangrene. Despite better understanding of pathogenesis and development of modern treatment technique, management of ASMVT remains a great clinical challenge. Transcatheter thrombolysis as the main revascularization method, combined with mechanical thrombectomy and other endovascular manipulations, alone or as a hybrid procedure, has got favorable outcomes. Thus on the basis of early diagnosis and close evaluation of intestinal ischemia and thrombus evolution, a coordinated stepwise management strategy involving a specialized approach of initial anticoagulation, preferred endovascular therapy, and damage-control surgery modality with surgical thrombectomy, may show benefits in rapid revascularization, prompt symptom improvement, and short bowel syndrome avoidance, with shortened hospitalization and less cost. This article presents an evidence-based review of the state-of-the-art advancements of this transcatheter thrombolysis centered stepwise management strategy for ASMVT.

Initial transcatheter thrombolysis for acute superior mesenteric venous thrombosis

AIM To determine the optimal initial treatment modality for acute superior mesenteric vein thrombosis (ASMVT) in patients with circumscribed peritonitis. METHODS A retrospective review was made of the Vascular Surgery Departments medical records to identify adult patients (≥ 18 years old) presenting with circumscribed peritonitis and diagnosed with ASMVT by imaging or endoscopic examination. Patients were selected from the time period between October 2009 and October 2012 to assess the overall performance of a new first-line treatment policy implemented in May 2011 for patients with circumscribed peritonitis, which recommends transcatheter thrombolysis with local anticoagulation and endovascular mechanical thrombectomy. Of the 25 patients selected for study inclusion, 12 had undergone emergency surgical exploration (group 1) and 13 had undergone the initial catheter-directed thrombolysis (group 2). Data extracted from each patients records for statistical analyses included method of diagnosis, symptoms, etiology and risk factors, thrombus location, initial management, morbidity, mortality, duration and total cost of hospitalization (in Renminbi, RMB), secondary operation, total length of bowel resection, duration of and findings in follow-up, and death/survival. RESULTS The two treatment groups showed similar rates of morbidity, 30-d mortality, and 1-year survival, as well as similar demographic characteristics, etiology or risk factors, computed tomography characteristics, symptoms, findings of blood testing at admission, complications, secondary operations, and follow-up outcomes. In contrast, the patients who received the initial non-operative treatment of transcatheter thrombolysis had significantly shorter durations of admission to symptom elimination (group 1: 18.25 ± 7.69 d vs group 2: 7.23 ± 2.42 d) and hospital stay (43.00 ± 13.77 d vs 20.46 ± 6.59 d), and early enteral or oral nutrition restoration (20.50 ± 5.13 d vs 8.92 ± 1.89 d), as well as significantly less total length of bowel resection (170.83 ± 61.27 cm vs 29.23 ± 50.24 cm) and lower total cost (200020.4 ± 91505.62 RMB vs 72785.6 ± 21828.16 RMB) (P < 0.05 for all). Statistical analyses suggested that initial transcatheter thrombolysis is correlated with quicker resolution of the thrombus, earlier improvement of symptoms, stimulation of collateral vessel development, reversal of intestinal ischemia, receipt of localizing bowel resection to prevent short bowel syndrome, shorter hospitalization, and lower overall cost of treatment. CONCLUSION For ASMVT patients with circumscribed peritonitis, early diagnosis is key to survival, and non-operative transcatheter thrombolysis is feasible and effective as an initial treatment.

Establishment of an Acute Superior Mesenteric Artery Injury Model for Damage Control Surgery

BACKGROUND Managements of superior mesenteric artery (SMA) injuries are difficult and often result in a disappointing outcome. Damage control surgery (DCS) has been approved to be an effective and reliable strategy for severe trauma victims. We aimed to build up a severe trauma-shock-hypothermia model of SMA injuries for DCS study and determine the optimal time to institute DCS. METHODS Pigs were anesthetized and instrumented with arterial and a thermodilution cardiac output catheter. SMA flow was interrupted while animals were hemorrhaged to 45% estimated blood volume. Pigs were maintained shock and intestine ischemia for three durations: intestine ischemia for 30 min (I-30; n = 6), 60 min (I-60; n = 6), and 90 min (I-90; n = 6). Cold lactated Ringers (10 mL/kg) was infused to induce hypothermia. SMA was then declamped and kept in reperfusion for 6 h. Hemodynamic data and serum samples were collected during shock and resuscitation. Distal ileum was collected at the end of ischemia and reperfusion. RESULTS All animals presented with disastrous conditions at the end of ischemia: low temperature, severe acidosis, decreased blood pressure, depressed cardiac output, and oxygen delivery. I-90 animals suffered the lowest temperature, the most severe acidosis, lowest blood pressure, and depressed cardiac output and oxygen delivery. Coagulopathy developed in I-90, whereas normal prothrombin time and thrombin time were detected in I-30 and I-60. Aspartate aminotransferase, lactate dehydrogenase, creatine kinase, and alkaline phosphatase were equally within groups (P > 0.05). All (6/6) of I-30, 83.3% (5/6) of I-60, and 16.7% (1/6) of I-90 pigs survived (P < 0.01). Base excess in I-90 was much lower than that in I-30 and I-60 animals. CONCLUSIONS We first built up an acute SMA injury animal model for DCS investigations and determined that the optimal institution time of DCS was before 60 min after SMA injury in the trauma-shock-hypothermia swine model.

Time Course Study on the Use of Temporary Intravascular Shunts as a Damage Control Adjunct in a Superior Mesenteric Artery Injury Model

BACKGROUND Temporary intravascular shunts (TIVS) are now widely used in vessels injuries. Little information concerned how long TIVS can safely maintain patency for in the setting of damage control surgery (DCS). We compared four different shunt-indwelling times in previous established superior mesenteric artery (SMA) injury models and aimed to find out the safest duration in the setting of DCS. METHODS SMA was clamped and completely transected while pigs were hemorrhaged. TIVS was inserted to the proximal and distal end of the transected SMA to restore blood flow. Twenty-four animals were resuscitated and randomized into four groups: group A (shunt for 3 hours), group B (shunt for 6 hours), group C (shunt for 9 hours), and group D (shunt for 12 hours). Angiography and duplex ultrasonography were periodically used to detect the patency of TIVS. Systemic hemodynamic parameters were recorded hourly, and intestine was collected at the end of the experiment. RESULTS Shunts in groups A and B maintained patency in all the six animals (100%) compared with only 50% (3 of 6) in group C and 0% (0 of 6) in group D. Intestine necrosis developed in all shunt-occluded animals, whereas reversible intestine ischemia-reperfusion injuries were found if shunts remained patency at the end of the experiment. CONCLUSIONS Our study suggests that TIVS can be used as an important DCS adjunct to maintain patency safely for 6 hours in SMA injury model.

Transcatheter thrombolysis combined with damage control surgery for treatment of acute mesenteric venous thrombosis associated with bowel necrosis: a retrospective study

ObjectiveThis study aims to evaluate the clinical outcomes of transcatheter thrombolysis in acute superior mesenteric venous thrombosis (ASMVT) associated with bowel necrosis.MethodsA retrospective study of six patients with ASMVT treated with catheter-directed thrombectomy/thrombolysis and damage control surgery at Jinling Hospital (Nanjing, China) between 2010 and 2013 was conducted. Demographics, past medical history, risk factors, therapeutic methods and effects, mortality, and follow-up of the study population were assessed.ResultsFive of six patients underwent arteriovenous combined thrombolysis, while one patient underwent arterial thrombolysis. All patients required damage control surgery, and four of these patients underwent temporary abdominal closure. All patients survived and were free of recurrence.ConclusionsTranscatheter thrombectomy/thrombolysis and damage control surgery could help avoid extensive bowel resection, prevent short bowel syndrome and reduce mortality for critically ill patients with acute mesenteric venous thrombosis associated with bowel necrosis.

D-dimer as an Early Marker of Severity in Patients With Acute Superior Mesenteric Venous Thrombosis

AbstractNo early serum marker of disease severity contributes to the treatment decision-making process of acute superior mesenteric venous thrombosis (ASMVT). This study aims to assess the value of serum D-dimer level in the first 3 days after admission as a severity marker of ASMVT patients.From May 2010 to June 2014, 50 consecutive patients of ASMVT were enrolled in this observational study. The serum D-dimer level was measured on a daily basis during the first 3 days after admission as well as other laboratory-testing parameters, clinical score, and outcome variables recorded during the same period. The maximum and mean D-dimer values were analyzed and compared with other potential markers for prediction of multiple-organ dysfunction syndrome (MODS) and short-bowel syndrome (SBS). The correlation of D-dimer level with other potential severity markers and inflammation parameters were also studied.Both maximum and mean D-dimer level during the first 3 days of admission were significantly higher in patients with several clinical variables such as death within 30 days, bowel resection, sepsis, abdominal compartment syndrome, MODS, and SBS. In addition, serum D-dimer level showed precise prediction for MODS and SBS, greater than L-lactate and intestinal-type fatty acid-binding protein (I-FABP). The D-dimer level was correlated well with L-lactate, I-FABP, and APACHE II score on the first 3 days of admission. Poor correlation of D-dimer level and inflammation parameters, white blood cell count, and C-reactive protein level, was detected.D-dimer level could be an effective, early, and specific serum marker indicating the clinical evolution and outcome of ASMVT.