RESUMO
OBJECTIVES: To propose a contemporary management strategy for venous injury during anterior lumbar spinal exposure that incorporates endovascular treatment. METHODS: Vein injuries suffered by patients treated in a single practice were reviewed. A treatment algorithm based on these experiences was formulated. RESULTS: Between 2015 and 2018, 914 patients received anterior access procedures for indicated lumbar interbody fusions. Of these patients, 15 (1.6%) suffered minor vascular injuries treated with manual pressure or suture repair. Four (0.4%) patients undergoing anterior lumbar spine surgery suffered major venous injuries, all of whom received the indicated spinal hardware following endovascular rescue. Primary repair was attempted in three patients before endovascular control and not at all in one. Vascular access was obtained via the bilateral femoral veins in 2 patients, unilateral femoral in one, and bilateral femoral plus right internal jugular vein in one. Stent choice included both uncovered (5, 63%) and covered stents (3, 38%). Deep venous thrombosis occurred in 2 patient's post-treatment. 1 DVT was encountered in the setting of a covered stent and 1 uncovered stent thrombosis was treated with catheter-directed lysis 4 weeks post-operatively. Ultimately, 3 patients were therapeutically anticoagulated. Mean follow-up is 13 months (range 1-36) with duplex ultrasounds available at 6 months or later in 3 of 4 patients. There is no evidence of post-thrombotic syndrome in the 2 patients that developed DVT's or in-stent stenosis in the 3 patients with available follow-up imaging. CONCLUSIONS: Endovascular techniques are important adjuncts when controlling large-volume hemorrhage associated with venous tears during anterior spinal exposure. Adequate direct compression allowing occlusion balloon inflation are key steps to reduce blood loss. Covered and uncovered stents are both appropriate choices to treat injuries. Patients must be anticoagulated post-operatively and surveilled for the sequelae of venous insufficiency. With expedient hemostasis, the indicated spinal surgery may be safely completed.
Assuntos
Perda Sanguínea Cirúrgica/prevenção & controle , Procedimentos Endovasculares , Técnicas Hemostáticas , Veia Ilíaca/lesões , Vértebras Lombares/cirurgia , Fusão Vertebral/efeitos adversos , Lesões do Sistema Vascular/terapia , Adulto , Anticoagulantes/uso terapêutico , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Feminino , Técnicas Hemostáticas/instrumentação , Humanos , Masculino , Pessoa de Meia-Idade , Síndrome Pós-Trombótica/tratamento farmacológico , Síndrome Pós-Trombótica/etiologia , Stents , Resultado do Tratamento , Lesões do Sistema Vascular/diagnóstico , Lesões do Sistema Vascular/etiologia , Trombose Venosa/tratamento farmacológico , Trombose Venosa/etiologia , Adulto JovemRESUMO
Peripheral vascular injuries are uncommon in civilian trauma but can threaten the patient's life or the viability of the limb. The definitive control of the vascular injury represents a surgical challenge, especially if the patient is hemodynamically unstable. This article proposes the management of peripheral vascular trauma following damage control surgery principles. It is essential to rapidly identify vascular injury signs and perform temporary bleeding control maneuvers. The surgical approaches according to the anatomical injured region should be selected. We propose two novel approaches to access the axillary and popliteal zones. The priority should be to reestablish limb perfusion via primary repair or damage control techniques (vascular shunt or endovascular approach). Major vascular surgeries should be managed post-operatively in the intensive care unit, which will allow correction of physiological derangement and identification of those developing compartmental syndrome. All permanent or temporary vascular procedures should be followed by a definitive repair within the first 8 hours. An early diagnosis and opportune intervention are fundamental to preserve the function and perfusion of the extremity.
El trauma vascular periférico no es común en el contexto civil, pero representa una amenaza para la vida del paciente o de la extremidad. El control definitivo de la lesión vascular representa un desafío quirúrgico, especialmente en pacientes con inestabilidad hemodinámica. Este artículo describe la propuesta de manejo del trauma vascular periférico de acuerdo con los principios de la cirugía de control de daños. Se debe identificar los signos sugestivos de lesión vascular y realizar oportunamente maniobras temporales para el control del sangrado. Se debe elegir el abordaje quirúrgico dependiendo del área anatómica lesionada. Se proponen dos nuevas incisiones para acceder a la región axilar y poplítea. La prioridad es restablecer la perfusión de la extremidad mediante el reparo primario o técnicas de control de daños (shunt vascular o abordaje endovascular). Los pacientes sometidos a cirugías vasculares mayores deben ser manejados postoperatoriamente en la unidad de cuidados intensivos para corregir las alteraciones fisiológicas e identificar aquellos que desarrollen un síndrome compartimental. Todos los procedimientos vasculares permanentes o temporales deben contar con un reparo definitivo en las primeras 8 horas. El diagnóstico temprano e intervención oportuna son fundamentales para salvaguardar la perfusión y funcionalidad de la extremidad.
Assuntos
Braço/irrigação sanguínea , Hemorragia/terapia , Perna (Membro)/irrigação sanguínea , Lesões do Sistema Vascular/cirurgia , Artéria Axilar/lesões , Artéria Axilar/cirurgia , Artéria Braquial/lesões , Artéria Braquial/cirurgia , Síndromes Compartimentais/diagnóstico , Consenso , Artéria Femoral/lesões , Artéria Femoral/cirurgia , Técnicas Hemostáticas , Humanos , Ilustração Médica , Artéria Poplítea/lesões , Artéria Poplítea/cirurgia , Complicações Pós-Operatórias/etiologia , Avaliação de Sintomas , Procedimentos Cirúrgicos Vasculares , Lesões do Sistema Vascular/classificação , Lesões do Sistema Vascular/diagnóstico , Lesões do Sistema Vascular/epidemiologiaRESUMO
In laparoscopic cholecystectomy (LC), the treatment of iatrogenic biliary tract injury has been given much attention. However, most accidental right hepatic artery (RHA) injuries are treated with simple clipping. The reason is that the RHA has difficulty in revascularization, and it is generally considered that RHA injury does not cause serious consequences. However, some studies suggest that some cases of RHA ligation can cause a series of pathological changes correlated to arterial ischemia, such as liver abscess, bile tumor, liver atrophy and anastomotic stenosis. Theoretically, RHA blood flow should be restored when possible, in order to avoid the complications of right hepatic ischemia. The present study involved two patients, including one male and one female patient. Both patients were admitted to the hospital with the diagnosis of chronic cholecystitis and gallbladder stone, and developed ischemia of the right half hepatic after accidental transection of the RHA. Both patients underwent continuous end-end anastomosis of the RHA with 6-0 Prolene suture. After the blood vessel anastomosis, the right half liver quickly recovered to its original bright red. No adverse complications were observed in follow-ups at three and six months after the operation. Laparoscopic repair of the RHA is technically feasible. Reconstruction of the RHA can prevent complications associated with right hepatic ischemia.
Assuntos
Colecistectomia/efeitos adversos , Cálculos Biliares/cirurgia , Artéria Hepática/lesões , Complicações Intraoperatórias/cirurgia , Laparoscopia/métodos , Procedimentos Cirúrgicos Vasculares/métodos , Lesões do Sistema Vascular/etiologia , Feminino , Artéria Hepática/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Lesões do Sistema Vascular/diagnóstico , Lesões do Sistema Vascular/cirurgiaRESUMO
Blunt popliteal vascular injury in the paediatric population is exceedingly rare and in advanced trauma centres the management can be challenging. A case of blunt popliteal artery trauma in a 5 years old requiring distal bypass using reversed saphenous vein is herein described. It is noteworthy to mention the difficulties experienced in a limited resource setting, including limitations in small rural hospitals, inefficient timely transfer to specialised centres, inadequate numbers of highly trained surgeons in subspecialities such as microvascular surgery and finally ineffective support and rehabilitative services.
Assuntos
Artéria Poplítea/lesões , Procedimentos Cirúrgicos Vasculares/métodos , Lesões do Sistema Vascular/cirurgia , Ferimentos não Penetrantes/cirurgia , Pré-Escolar , Angiografia por Tomografia Computadorizada , Humanos , Masculino , Artéria Poplítea/diagnóstico por imagem , Artéria Poplítea/cirurgia , Lesões do Sistema Vascular/diagnóstico , Ferimentos não Penetrantes/diagnósticoRESUMO
PURPOSE: Peri-operative major arterial haemorrhage after revision total hip arthroplasty (RTHA) is an odd but limb- and life-threatening complication. In this retrospective analysis, we sought to determine the prevalence of such injuries requiring selective catheter embolization or bypass after RTHA and to evaluate the associated mortality rate. METHODS: Between 1995 and 2016, 2524 RTHAs were performed at a high-volume centre (1031 one-stage revisions, 1370 two-stage revisions and 123 resection arthroplasties). Throughout this period, nine patients presented with signs of persistent bleeding unaddressed during index surgery (9/2524; 0.35%), causing haemodynamic instability. All patients underwent angiographic exploration within the first 24 post-operative hours. Angiography evidenced four cases of bleeding pseudoaneurysms (three of them related to the common femoral artery and one to the medial circumflex femoral artery) and five cases of direct lacerations (one case in the inferior epigastric artery, one in the hypogastric artery, one in the external iliac artery, one in the popliteal artery and another in the superior gluteal artery). RESULTS: Six cases underwent selective percutaneous angiographic embolization with gelatin microspheres, obtaining immediate haemodynamic stabilization; whereas three cases required a further bypass surgery with synthetic graft. Of the former group, four patients had an uneventful evolution, while two died at a mean of 49 days after surgery due to multi-organ failure (MOF). Two cases of the bypass group died because of MOF at a mean of 22 days. Overall mortality rate was 44%. CONCLUSIONS: The overall risk of arterial injury associated with RTHA was low. However, recognition of such a complication is imperative since it was associated with a high mortality rate.
Assuntos
Artroplastia de Quadril/efeitos adversos , Lesões do Sistema Vascular/diagnóstico , Lesões do Sistema Vascular/terapia , Idoso , Idoso de 80 Anos ou mais , Angiografia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Reoperação , Estudos Retrospectivos , Lesões do Sistema Vascular/etiologia , Lesões do Sistema Vascular/mortalidadeRESUMO
O aneurisma arterial induzido por uso de muleta é um evento raro, e a associação com aneurismas venosos não está descrita na literatura. Relatamos o caso de uma paciente que, após o uso prolongado dessa órtese, apresentou quadro de isquemia aguda de membro superior secundária à trombose de um aneurisma da artéria braquial, associado ao achado incidental de aneurismas da veia braquial. Embora a principal causa de oclusão arterial aguda de membro superior seja a embolização de fonte cardíaca, deve-se considerar a possibilidade de embolização arterioarterial por aneurismas provocados pelo uso prolongado de muletas. Os aneurismas venosos também devem ser suspeitados, uma vez que podem ser sede de trombos e fonte de êmbolos pulmonares
Crutch-induced arterial aneurysm is a rare event and there are no descriptions in the literature of cases with concomitant venous aneurysms. We report the case of a patient who, after prolonged crutch use, presented with acute ischemia of the upper limb secondary to brachial artery aneurysm thrombosis, associated with the incidental finding of brachial vein aneurysms. Although the main cause of acute upper limb occlusion is embolization of cardiac origin, consideration should be given to the possibility of arterio-arterial embolization due to an aneurysm induced by prolonged use of crutches. Venous aneurysms should also be suspected since they can be sites of thrombosis, and a source of pulmonary embolism
Assuntos
Humanos , Feminino , Idoso , Aneurisma/cirurgia , Artéria Braquial/lesões , Muletas , Embolectomia com Balão/métodos , Isquemia , Aparelhos Ortopédicos/efeitos adversos , Trombose , Ultrassonografia Doppler/métodos , Extremidade Superior , Lesões do Sistema Vascular/complicações , Lesões do Sistema Vascular/diagnósticoRESUMO
Introducción: el manejo adecuado del trauma vascular es uno de los aspectos más difíciles en la asistencia al paciente politraumatizado. Las lesiones de vasos periféricos tienen un potencial de ocasionar morbimortalidad si no se reconocen o tratan inmediatamente. Objetivo: describir las experiencias en el diagnóstico y tratamiento de las lesiones vasculares, a partir de las características de los pacientes para el enriquecimiento del conocimiento en la asistencia medica. Métodos: se realizó un estudio descriptivo de los pacientes atendidos con traumatismo vascular durante el período de junio de 2005 a diciembre de 2008, en un país de la región asiática. Los resultados se expresan en tablas de porcentajes, para las variables correspondientes a la etiología, topografía de las lesiones, técnicas quirúrgicas utilizadas y resultados del tratamiento. Resultados: se atendieron 46 pacientes con 57 lesiones vasculares, todos hombres menores de 45 años. De ellas el 52,6 se localizaron en los miembros inferiores y la arteria femoral superficial fue la más dañada, con un 19,2 por ciento del total. Se logró conservar la extremidad en el 95,7 por ciento de los pacientes atendidos. Conclusiones: los hombres menores de 45 años y heridos por arma de fuego, fueron más afectados, así como los vasos de miembros inferiores con poca diferencia respecto a los de miembros superiores(AU)
Introduction: The adequate management of vascular trauma is one of the most difficult aspects in polytraumatized patient care. Peripheral vessel lesions have the potential to cause morbidity and mortality if they are not diagnosed or treated immediately. Objective: To describe the experiences in the diagnosis and treatment of vascular lesions, based on the characteristics of the patients for the knowledge improvement of medical care. Results: 46 patients with 57 vascular lesions were treated, all men younger than 45 years. 52.6 percent of lesions were located in the lower limbs, and the superficial femoral artery was the most damaged, with 19.2 percent of the total. The limb was preserved in 95.7percent of patients treated. Conclusions: Men younger than 45 years and gunshot wounded were more affected, as were vessels of lower limbs with little difference from those of upper limbs(AU)
Assuntos
Humanos , Masculino , Pessoa de Meia-Idade , Armas de Fogo/estatística & dados numéricos , Artéria Femoral/lesões , Lesões do Sistema Vascular/diagnóstico , Epidemiologia Descritiva , Lesões do Sistema Vascular/terapiaRESUMO
AIM: To report experience with liver resection in a select group of patients with postoperative biliary stricture associated with vascular injury. METHODS: From a prospective database of patients treated for benign biliary strictures at our hospital, cases that underwent liver resections were reviewed. All cases were referred after one or more attempts to repair bile duct injuries following cholecystectomy (open or laparoscopic). Liver resection was indicated in patients with Strasberg E3/E4 (hilar stricture) bile duct lesions associated with vascular damage (arterial and/or portal), ipsilateral liver atrophy/abscess, recurrent attacks of cholangitis, and failure of previous hepaticojejunostomy. RESULTS: Of 148 patients treated for benign biliary strictures, nine (6.1%) underwent liver resection; eight women and one man with a mean age of 38.6 years. Six patients had previously been submitted to open cholecystectomy and three to laparoscopic surgery. The mean number of surgical procedures before definitive treatment was 2.4. All patients had Strasberg E3/E4 injuries, and vascular injury was present in all cases. Eight patients underwent right hepatectomy and one underwent left lateral sectionectomy without mortality. Mean time of follow up was 69.1 mo and after long-term follow up, eight patients are asymptomatic. CONCLUSION: Liver resection is a good therapeutic option for patients with complex postoperative biliary stricture and vascular injury presenting with liver atrophy/abscess in which previous hepaticojejunostomy has failed.
Assuntos
Colecistectomia/efeitos adversos , Colestase/cirurgia , Hepatectomia , Lesões do Sistema Vascular/cirurgia , Adulto , Brasil , Colestase/diagnóstico , Colestase/etiologia , Constrição Patológica , Bases de Dados Factuais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reoperação , Estudos Retrospectivos , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Lesões do Sistema Vascular/diagnóstico , Lesões do Sistema Vascular/etiologiaRESUMO
BACKGROUND: Trauma is the leading cause of injury and death for individuals aged 1-44 years. Up to 8% of the US population participates in winter sports, and although vascular injuries are uncommon in these activities, little is published in this area. We sought to identify the incidence, injury patterns, and outcomes of vascular injuries resulting from winter sports trauma. METHODS: Patients with winter sports trauma and the subset with vascular injuries were identified by accessing the National Trauma Data Bank querying years 2007-2010. Patients with and without vascular injuries were then compared. Admission variables included transport time, emergency department hypotension (systolic blood pressure < 90), Glasgow Coma Scale ≤ 8, Injury Severity Score ≥ 25, fractures, solid organ injury, and vascular injury. Outcomes were analyzed and associations with vascular injuries were determined. RESULTS: A total of 2,298 patients were identified with winter sports-related trauma and 28 (1.2%) had associated vascular injuries. Overall, the top 3 injuries were head trauma (16.7%), thoracic vertebral fractures (5.5%), and lumbar vertebral fractures (5.1%). The most common associated vascular injures were to the popliteal artery (17.7%), splenic artery (14.7%), and brachial blood vessels (14.7%). In the entire cohort, 1 patient (0.04%) suffered an amputation and 15 patients (0.7%) died. There were no amputations in the vascular injury group. Mortality was 0.6% in patients without a vascular injury compared with 7.1% of those with a vascular injury (P = 0.01). CONCLUSIONS: Although vascular injury is an uncommon associated finding in winter sports trauma, it is associated with a significant increase in mortality. These findings highlight the need for rapid identification of traumatic vascular injuries, which predicts worse overall outcomes in this patient population.
Assuntos
Traumatismos em Atletas/mortalidade , Traumatismo Múltiplo/mortalidade , Estações do Ano , Lesões do Sistema Vascular/mortalidade , Adolescente , Adulto , Traumatismos em Atletas/diagnóstico , Traumatismos em Atletas/terapia , Feminino , Escala de Coma de Glasgow , Humanos , Incidência , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Traumatismo Múltiplo/diagnóstico , Traumatismo Múltiplo/terapia , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Lesões do Sistema Vascular/diagnóstico , Lesões do Sistema Vascular/terapia , Adulto JovemRESUMO
O trauma da mão é uma das lesões mais frequentes nas emergências. O trauma complexo envolve lesões de múltiplas estruturas e tecidos da mão. O objetivo principal deste trabalho é esclarecer os conceitos envolvidos no estudo do paciente com trauma complexo da mão, mais especificamente, na avaliação inicial e manejo primário da mão traumatizada. Procuramos orientar a conduta dos médicos nas diversas situações clínico-cirúrgicas, que envolvem esta patologia, objetivando um julgamento rápido e adequado, interferindo positivamente no desenvolvimento natural da doença, como também nas sequelas decorrentes ao traumatismo. Nesta primeira parte, são abordados os fundamentos e conceitos considerados essenciais na abordagem do traumatismo da mão, lesão vascular, lesão nervosa e lesão tendínea, enfatizando os benefícios de uma conduta multifatorial e assertiva, abarcando as diversas disciplinas envolvidas no atendimento primário do paciente vítima de trauma (AU)
Trauma of the hand is one of the most frequent injuries in emergencies. Complex trauma involves injuries to multiple tissues and structures of the hand. The main purpose of this work is to clarify the concepts involved in the study of patients with complex trauma of the hand, more specifically, the initial assessment and primary management of the traumatized hand. We seek to guide the conduct of physicians in different clinical and surgical situations involving this pathology. Aiming for a quick and proper judgment, interfering positively with the natural development of the disease and also with sequelae resulting from trauma. In this first part the article discusses the fundamentals and concepts considered essential in the management of hand trauma, vascular injury, nerve injury and tendon injury, emphasizing the benefits of a multifactorial and assertive approach, covering the various disciplines involved in primary care of the trauma patient (AU)