Traumatic extremity arterial injury in children: Epidemiology, diagnostics, treatment and prognostic value of Mangled Extremity Severity Score

<p>Abstract</p> <p>Background</p> <p>Traumatic paediatric arterial injuries are a great challenge due to low incidence and specific characteristics of paediatric anatomy and physiology. The aim of the present study was to investigate their epidemiology, diagnostic and therapeutic options and complications. Furthermore, the prognostic value of the Mangled Extremity Severity Score (MESS) was evaluated.</p> <p>Methods</p> <p>In a retrospective clinical study 44 children aged 9.0 ± 3.2 years treated for traumatic extremity arterial lesions in our Level I trauma center between 1971 and 2006 were enrolled. Exclusion criteria were age > 14, venous and iatrogenic vascular injury. Demographic data, mechanism of injury, severity of arterial lesions (by Vollmar and MESS), diagnostic and therapeutic management, complications and outcome were evaluated.</p> <p>Results</p> <p>The most commonly injured vessel was the femoral artery (25%) followed by the brachial artery (22.7%). The mechanism of injury was penetrating (31.8%), isolated severe blunt extremity trauma (29.6%), multiple trauma (25%) and humeral supracondylar fractures (13.6%). In 63.6% no specific vascular diagnostic procedure was performed in favour of emergency surgery. Surgical reconstructive strategies were preferred (68.2%). A MESS < 7 was associated with initial (p < 0.05) and definite limb salvage (p < 0.001) of the lower extremity.</p> <p>Conclusions</p> <p>Traumatic paediatric vascular injuries are very rare. The most common situations of vascular lesions in childhood were penetrating injuries and fractures of the extremities either as isolated injuries or in multiply injured patients. In paediatric patients, the MESS could serve as a basis for decision making for limb salvage or amputation.</p

The safety of moderate hypothermic lower body circulatory arrest with selective cerebral perfusion: A propensity score analysis

ObjectiveThere is no common guideline on what temperature should be achieved at the lower body circulatory arrest followed by the initiation of selective cerebral perfusion.MethodsBetween October 1999 and August 2005, a total of 377 patients underwent repair of the aortic arch with selective cerebral perfusion and hypothermic circulatory arrest at 20°C to 28°C and were divided into two groups: (1) 125 patients with deep lower body circulatory arrest at 20°C to 24.9°C (deep lower body circulatory arrest group) and (2) 252 patients with moderate lower body circulatory arrest at 25°C to 28°C (moderate lower body circulatory arrest group). To compensate for the differences in patient characteristics, we used a propensity score matching analysis, and comparable patients, 92 patients from each group, were identified for final analysis.ResultsThere were no significant differences in mortality or morbidity between deep and moderate lower body circulatory arrest, in either the entire study cohort or the propensity-matched cohort. C-reactive protein level 1 day after the operation approached but fell short of significance (108.4 ± 47.7 mg/L in deep lower body circulatory arrest group and 95.8 ± 44.2 mg/L in moderate lower body circulatory arrest group, P = .07). The mean temperatures at the initiation of lower body circulatory arrest were 24.1°C ± 2.2°C in patients who underwent reexploration for bleeding and 24.9°C ± 1.8°C in patients who did not (P = .025); the difference also reached statistical significance in multivariate analysis (P = .046, odds ratio 0.796).ConclusionsOur results suggest that moderate lower body circulatory arrest can be safely performed for aortic arch repair. In fact, postoperative inflammatory response tended to be lower in patients with moderate lower body circulatory arrest than those with deep lower body circulatory arrest, and deep lower body circulatory arrest was a strong risk factor for reexploration for bleeding

Total aortic arch replacement with a novel four-branched frozen elephant trunk graft: first-in-man results †

Abstract OBJECTIVES: The combined disease of the aortic arch and the proximal descending aorta remains a surgical challenge. With the &apos;frozen elephant technique&apos;, the ascending aorta, along with the aortic arch, is replaced conventionally and an endovascular stent graft is placed into the descending aorta in the antegrade manner through the open aortic arch, thereby potentially allowing for a &apos;singlestage&apos; operation. The purpose of this study was to assess the feasibility of a novel four-branched hybrid graft (Vascutek, Scotland). METHODS: From April 2010 to August 2011, 34 patients (25 males, age 60 ± 14 years) were operated on [14 aneurysms, 20 dissections (18 acute)]. Ten of these patients had undergone previous cardiac operations. The collapsed endoprosthesis was deployed in the descending aorta through the opened aortic arch. A sewing collar between the graft segments simplified the &apos;distal&apos; anastomosis. The fourbranched graft segment allowed the replacement of the aortic arch and supra-aortic vessels individually. Concomitant procedures were performed if necessary. RESULTS: There were three deaths within the 30 postoperative days. All of them were of AADA patients. The mean cardiopulmonary bypass time was 254 ± 53 min, aortic cross clamp time was 148 ± 48 min and circulatory arrest time was 48 ± 22 min. Aortic valvesparing root surgery was performed in 12 patients, Bentall procedure in four, CABG in three and mitral valve repair in two. In one patient, a secondary endovascular extension of the stent graft was necessary to reach the landing zone. In all others, postoperative CT-Scans confirmed the desired results. CONCLUSIONS: The graft adds to the &apos;frozen elephant trunk&apos; concept for treating the arch and proximal descending aorta. Early experience demonstrates an excellent 30-day survival. Combining the frozen elephant with a four-branched arch graft increases the armament of the surgeon in the treatment of complex and diverse aortic arch pathology

Immediate surgical coronary revascularisation in patients presenting with acute myocardial infarction

Background: The number of patients presenting with acute myocardial infarction (AMI) and being untreatable by interventional cardiologists increased during the last years. Previous experience in emergency coronary artery bypass grafting (CABG) in these patients spurred us towards a more liberal acceptance for surgery. Following a prospective protocol, patients were operated on and further analysed. Methods: Within a two year interval, 127 patients (38 female, age 68 +/- 12 years, EuroScore (ES) II 6.7 +/- 7.2\%) presenting with AMI (86 non-ST-elevated myocardial infarction (NSTEMI), 41 STEMI) were immediately accepted for emergency CABG and operated on within six hours after cardiac catheterisation (77\% three-vessel-disease, 47\% left main stem stenosis, 11\% cardiogenic shock, 21\% preoperative intraaortic balloon pump (IABP), left ventricular ejection fraction 48 +/- 15\%). Results: 30-day-mortality was 6\% (8 patients, 2 NSTEMI (2\%) 6 STEMI (15\%), p=0.014). Complete revascularisation could be achieved in 80\% of the patients using 2 +/- 1 grafts and 3 +/- 1 distal anastomoses. In total, 66\% were supported by IABP, extracorporal life support (ECLS) systems were implanted in two patients. Logistic regression analysis revealed the ES II as an independent risk factor for mortality (p&lt;0.001, HR 1.216, 95\%-CI-Intervall 1.082-1.366). Conclusions: Quo ad vitam, results of emergency CABG for patients presenting with NSTEMI can be compared with those of elective revascularisation. Complete revascularisation obviously offers a clear benefit for the patients. Mortality in patients presenting with STEMI and cardiogenic shock is substantially high. For these patients, other concepts regarding timing of surgical revascularisation and bridging until surgery need to be taken into consideration

Aortic root surgery in septuagenarians: impact of different surgical techniques

<p>Abstract</p> <p>Background</p> <p>To evaluate the impact and safety of different surgical techniques for aortic root replacement (ARR) on early and late morbidity and mortality in septuagenarians undergoing ARR.</p> <p>Methods</p> <p>Ninety-five patients (73.8 ± 3.2 years) were operated and divided into three groups according to the aortic root procedure; MECH-group (n = 51) patients with a mechanical composite graft, BIO-group (n = 22) patients with a customized biological composite graft, and REIMPL-group (n = 22) patients with a valve sparing aortic root reimplantation (David I). In 42.1% (40/95) of these patients the aortic arch was replaced. Follow-up was completed in 95.2% (79/83) of in-hospital survivors.</p> <p>Results</p> <p>Hospital mortality was 12.6% (12/95) in the entire population (MECH. 15.7% (8/51), BIO 19.7% (4/22), REIMPL 0% (0/22); p = 0.004). Two patients died intraoperatively. The most frequent postoperative complications were prolonged mechanical ventilation ((>48 h) in 16.8% (16/93) (MECH. 7% (7/51), BIO 36.4% (8/22), REIMPL 4.5% (1/22); p = 0.013) and rethoracotomy for postoperative bleeding in 12.6% (12/95) (MECH. 12% (6/51), BIO 22.7% (5/22), REIMPL 4.5% (1/22); p = 0.19). Nineteen late deaths (22.9%) (19/83) (MECH 34.8% (15/43), BIO 16.7% (3/18), REIMPL 4.5% (1/22); p = 0.012) occurred during a mean follow-up of 41 ± 42 months (MECH 48 ± 48 months, BIO 25 ± 37 months, REIMPL 40 ± 28 months, p = 0.028). Postoperative NYHA class decreased significantly (p = 0.017) and performance status (p = 0.027) increased for the entire group compared to preoperative values.</p> <p>Conclusion</p> <p>Our data indicate that valve sparing aortic root reimplantation is safe and effective in septuagenarians, and is associated with low early and late morbidity and mortality.</p