Treatment of blunt thoracic aortic injury in Germany—Assessment of the TraumaRegister DGU®

Purpose Using the data delivered by the German Trauma Register DGU® from 2002 till 2013, the value of different therapies of blunt thoracic aortic injury (BTAI) in Germany was analyzed. Methods Prospectively collected data of patients suffering from BTAI were retrospectively analyzed with focus on the different treatment modalities for grade I–IV injuries. Results 821 patients suffering from BTAI were identified: 51.6% (424) grade I injury, 35.4% (291) grade II or III injury and 12.9% (106) grade IV injury (77.5% men [44.94 ± 20.6 years]). The main patterns of injury were high- speed accidents and falls (78.0% [n = 640], 21.8% [n = 171] respectively). Significant differences between grade I and grade II/III as well as IV injuries could be assessed for the incidence of cardiopulmonary resuscitation, a Glasgow Coma Scale score below 8 and a systolic blood pressure below 90 mmHg (p-value: <0.001). In the primary admission subgroup, 44.1% (197/447) of the patients received best medical treatment, 55.9% received surgical intervention (250/447): Thereof 37.2% (93/250) received open surgery and 62.8% (147/250) had been treated by endovascular means. Significantly lower 24-h- and in-hospital-mortality rates were encountered after endovascular treatment for all gradings of BTAI (p-value: <0.001). Yet this subgroup of patients showed the lowest incidence of further severe injuries and cardiac arrest. Conclusion Endovascular therapy became the treatment of choice for BTAI in Germany. Patients who have been treated by surgical means showed the highest survival rate, especially endovascular therapy showed a favorable low mortality rate

Nightmare after iliac vein stenting: Spinal epidural hematoma

Abstract Spinal epidural hematoma is a rare but devastating complication of iliac vein stenting. Radicular back pain during and after procedure is an alarming sign for this complication

Intraoperative Hemoadsorption (Cytosorb™) during Open Thoracoabdominal Aortic Repair: A Pilot Randomized Controlled Trial

Background: The efficacy of cytokine adsorption in controlling the early inflammation cascade after open thoracoabdominal aortic (TAAA) repair has not been investigated. The aim of this pilot randomized controlled trial was to assess the feasibility and effect of perioperative hemoadsorption during open TAAA repair. Methods: Patients scheduled for open TAAA repair with the use of cardiopulmonary bypass (CPB) were included. The patients were randomized the day before surgery to either intraoperative hemoadsorption during CPB or standard of care. Results: A total of 10 patients were randomly assigned to the intervention group, whereas the control group consisted of 17 patients (mean age of the total cohort, 51.1 ± 11.2 years, 67% male, 3 patients not randomized). The majority of baseline and perioperative characteristics were similar, and no device-related adverse events were reported. A trend to shorter ventilation times in the intervention group was observed (median 88 h vs. 510 h, p = 0.08, Δ422). Severe acute respiratory distress syndrome was significantly less in the intervention patients (p = 0.02). Conclusions: This is the first pilot study showing that the intraoperative use of hemoadsorption in open TAAA repair patients may be feasible and safe, yet larger trials are needed to evaluate whether intraoperative hemoadsorption is associated with improved clinical outcomes

Factors associated with difficulty in stenting the chronic iliofemoral venous obstruction

BACKGROUND: The main aim of this article is to investigate the causes of technical failure during endovascular recanalization in patients with post-thrombotic syndrome with occluded iliofemoral veins and to suggest alternative techniques to improve outcomes in such challenging cases. METHODS: Between November 2015 and August 2020, 230 patients (274 limbs) treated in our institution with symptomatic chronic iliofemoral venous obstruction underwent endovascular recanalization with angioplasty and stent placement. Overall, the initial attempt was unsuccessful in 15 limbs. We retrospectively analyzed the basic demographic and health characteristics of the involved patients and evaluated the endovascular procedures and techniques that resulted in a successful second intervention. RESULTS: The first attempts at endovascular intervention were unsuccessful in 15 of the 274 limbs (5.4%). Failures were attributed to hostile groin areas in intravenous drug abusers caused by multiple punctures in six cases. In addition, five interventions failed due to prior surgery at the site of venous occlusion and in retroperitoneal space, three patients due to severe stent deformity, and one patient due to congenital venous aplasia. Of the 15 patients, 11 underwent a subsequent attempt that included six successful recanalizations. The mean follow-up time of the six patients with successful recanalization was 27 months (5-62 months). The primary, assisted primary and secondary patency rates were 83.3%, 100%, and 100%, respectively. The remaining five patients, in whom the second recanalization attempt failed, received conservative treatment. CONCLUSIONS: Recanalization failure is rare in chronic venous obstruction patients. Severe stent deformities have the lowest chance of successful second intervention. Patients with a hostile groin or prior open surgeries at the occlusion site may be considered for reintervention with a success rate of nearly 50%

Assessment of the lymphatic system by indirect lymphography in patients with post-thrombotic syndrome

OBJECTIVE: Alterations in lower extremity lymph drainage caused by chronic venous obstruction (CVO) are not well studied, partially due to a lack of standardized imaging modalities to assess the quality of lymphatic drainage in the lower extremities of patients with postthrombotic syndrome (PTS). However, these changes are likely to have an impact on the severity of disease and clinical outcomes of intervention. In the current study, we investigated the feasibility and diagnostic value of pre-intervention indirect lymphography in patients with CVO along with their pre and post intervention Villalta scores. METHODS: A total of 17 patients (21 limbs) with iliofemoral and caval CVO were included in the study between 2017 and 2018. The deep and superficial lymphatic vessels in both legs were assessed before venous recanalization and stenting. The quality of lymphatic flow was compared in legs with CVO and healthy legs. Moreover, the correlation between lymphatic changes and clinical severity of PTS was evaluated by the Villalta score and CEAP classification. RESULTS: The mean patient age was 44 ± 12 years and 10 (59%) patients were female. Patients were treated a mean 25 ± 6 months after their first deep venous thrombosis (DVT). Five patients (29%) suffered from recurrent DVT. Mean pre-interventional Villalta score was 10.5 ± 1.46, post-interventional Villalta was 9.27 ± 1.12 (p:0.0096). Regarding the CEAP classification, 4 legs were in class 5, seven legs were in class 4, three legs were in class 3 and 2 respectively. The primary patency rate was 70.5% and secondary patency rate 82.5% after a mean 18-months of follow-up. Indirect lymphography of the superficial and deep lymphatic system was completed prior to intervention in both legs of all patients. According to qualitative criteria, abnormal lymphatic vessel function was found in 35.2% of the superficial and 58.8% of the deep lymphatic vessels of the affected legs. Further analysis in patients showed abnormal function of deep lymphatic vessels in all patients with moderate to severe PTS according to the Villalta score. CONCLUSION: Indirect lymphography is a feasible diagnostic tool to evaluate the function of lymphatic vessels. Impaired drainage of the deep lymphatic system was found in all patients with moderate to severe PTS. The clinical meaning of these lymphatic changes is not clear, but an association with clinical severity and outcome is possible

Wound complications after common femoral vein endophlebectomy: Influence on outcome

Introduction Venous recanalization of obstructed femoral and iliac veins is associated with good results regarding the feasibility and patency rate. If the common femoral vein with its inflow vessels is involved, open surgical desobliteration or endophlebectomy has been described as a crucial part of the intervention. However, when performing the hybrid procedure, a number of specific complications have been described. We present our results after venous recanalization including an endophlebectomy, focussing on wound complications and its impact on outcome. Material and methods A retrospective analysis of prospective recorded data of all patients who underwent a hybrid procedure for chronic obstruction of iliofemoral veins between 2010 and 2015 was performed. The patients were treated by recanalization of the affected veins combined with endophlebectomy of the common femoral vein and arteriovenous fistula implantation. Data assessment focussed on complications and patency rates. Results This study includes 96 patients, thereof 58 females with a mean age of 44.1 years. The mean procedure time was 344140min (range 124-663). Median follow-up time was 12.5 months (2-33 months). Primary patency was 62.5% and secondary patency was 90%. Re-intervention due to early occlusion within the first 30 post-intervention days was necessary in 37.5% of all cases. Besides bleeding complications, wound complications, mainly classified as Szilagyi I, occurred in 33% of all patients. A multivariate analysis showed a significant impact of wound complications on primary as well as secondary patency rate (p=0.032, respectively 0.015). Conclusion Recanalization of obstructed iliac veins and/or the inferior vena cava combined with endophlebectomy of the common femoral vein and arteriovenous fistula implantation is a safe and feasible treatment option in the post-thrombotic syndrome. As wound complications are a common and associated with a significant impact on patency rate, further attempts to improve the procedure are crucial

Extra-Thoracic Supra-aortic Bypass Surgery Is Safe in Thoracic Endovascular Aortic Repair and Arterial Occlusive Disease Treatment

Objective: The safety and feasibility of supra-aortic debranching as part of endovascular aortic surgery or as a treatment option for arterial occlusive disease (AOD) remains controversial. The aim of this study was to assess the clinical outcome of this surgery. Methods: This single centre, retrospective study included 107 patients (mean age 69.2 years, 38.4% women) who underwent supra-aortic bypass surgery (carotidesubclavian bypass, carotidecarotid bypass, and carotide carotidesubclavian bypass) because of thoracic or thoraco-abdominal endovascular aortic repair (57%; 61/107) or as AOD treatment (42.9%; 46/107) between January 2006 and January 2015. Mortality, morbidity with a focus on neurological complications, and patency rate were assessed. Twenty-six of 107 (14.2%) of the debranching patients were treated under emergency conditions because of acute type B dissection or symptomatic aneurysm. Follow up, conducted by imaging interpretation and telephone interviews, continued till March 2017 (mean 42.1, 0-125, months). Results: The in hospital mortality rate was 10.2% (11/107), all of these cases from the debranching group and related to emergency procedures (p &lt; .0001). One procedure related death of a patient in the debranching group, who had a lethal stroke 72 months post-operatively following bypass occlusion was observed. Early neurological complications were recognised in 10 patients, including two transient cases of Horner syndrome and vocal cord paralysis as well as six cases of phrenic nerve apraxia. Three cases of stenosis and one case of occlusion were successfully treated. In three AOD patients, the graft had to be exchanged because of peri-graft reaction. Primary and secondary patency rates of 96 patients after 36 months were 95% (SE 2.6%) and 98% (SE 1.8%), respectively. Conclusions: Extra-thoracic supra-aortic bypass surgery involves low complication rates and high mid-term bypass patency rates. It is a safe and feasible treatment option in the form of debranching in combination with endovascular aortic aneurysm repair and in AOD. (C) 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved