Assessment of the thrombogenic effect of fibrin sealant dressing in a vascular surgery model in rabbits.

This study's objective was to investigate the potential thrombogenic effects of thrombin-containing fibrin sealant dressings (FSD) in a vascular repair model. Oval-shaped pieces of the rabbit abdominal aorta and vena cava were excised, the injuries were repaired with FSD, and animals were allowed to recover. Thrombus formation was examined by (1) an infusion of indium-labeled platelets into the rabbits following FSD application and estimation of total number of platelets attached to the wounds at 2, 4, and 6 h later (short-term effect, n = 12); and by (2) morphological and histological examinations of the vessels and dressings on days 1, 3, and 7 after repair operation in another group of rabbits (long-term effect, n = 12). Application of FSD sealed the vascular injures and produced immediate hemostasis that was stable up to 1 week. The highest numbers of platelets (both native and labeled) adhered to the arterial and venous repair sites were 6.5 x 106 and 4.4 x 107, respectively, 6 h after operation. The adhered platelets, however, did not form a visible and clinically significant thrombus. In long-term experiments, no evidence of thrombus was found in the lumens of the repaired vessels or on the dressings, and no microthrombi were detected histologically in other tissues at any time point. Although vena caval injuries showed signs of healing at day 7 postoperatively, the aortic wounds expanded progressively (pseudoaneurysm) and were prone to rupture at later times. Thus, direct exposure of FSD does not cause intravascular thrombosis or thrombotic events in rabbits. The dressing appears to be safe and effective for short-term repair of vascular injuries. It may also allow healing of minor venous defects, but cannot replace conventional surgical techniques (suturing) for permanent repair of arterial damages.     

可注射型及柱型藻酸钙载体联合运用修复兔膝关节软骨缺损的效果观察

目的：使用软骨细胞、可注射藻酸钙及柱型藻酸钙载体，修复兔股骨髁间非负重区骨软骨缺损，观察同种材料不同形态联合修复的效果。方法：将24只新西兰大白兔随机分成4组，第1组给予注射藻酸钙凝胶修复，第2组放置单纯柱型藻酸钙载体修复，第3组放置柱型藻酸钙载体后于周缘注射凝胶，第4组为空白不用任何支架材料修复。每只动物修复效果以Xij表示，以定量的方法统计出所有动物修复效果，以评分的形式表示，作统计学分析。结果：实验组与对照组一共4组数据，统计每组（i）中每只兔（j）膝关节软骨缺损修复效果评分Xij，然后进行组间比较。根据单向方差分析的思想，用SPSS 12．0软件计算F=69．0，P〈0．05，联合修复组效果好于其他各组。结论：柱型藻酸钙载体具有良好的成型效果且有一定的机械强度，可注射藻酸钙凝胶具有良好的黏附性，用于人工材料与正常结构的整合具有明显优势，两者联合修复软骨缺损，优势互补，符合软骨组织工程的修复与整合的要求。     

Inferior vena cava injuries--a continuing challenge

The mortality from abdominal vena cava trauma remains in excess of 33% despite advances in prehospital and intraoperative care. During the 7-year period ending December 1981, 58 patients with vena cava injuries were treated at our institution. Thirty-nine (67%) were due to gunshot wounds, nine to stab injuries, and ten to blunt trauma. Overall mortality was 38%. Predictors of poor survival were: 1) presence of shock upon hospital arrival; 2) multiple abdominal vascular injuries; and 3) injuries in the retrohepatic segment. Only two (17%) of 12 patients survived retrohepatic wounds despite various shunting techniques. Of the remaining 12 deaths, 11 (92%) had associated major vascular trauma that included four portal system, three aortic, and three iliac artery injuries. This contrasts to a 96% survival rate for the 28 patients without associated abdominal vascular injuries. Our experience underscores the importance of rapid resuscitation, early operation, and searching for associated vascular injuries before a time-consuming repair of the vena cava is undertaken. Improving the survival of patients with blunt retrohepatic cava and hepatic vein trauma remains a dilemma.     

Molecular mechanisms of enhanced wound healing by copper oxide‐impregnated dressings

Copper plays a key role in angiogenesis and in the synthesis and stabilization of extracellular matrix skin proteins, which are critical processes of skin formation. We hypothesized that introducing copper into wound dressings would enhance wound repair. Application of wound dressings containing copper oxide to wounds inflicted in genetically engineered diabetic mice (C57BL/KsOlaHsd‐Lepr^db) resulted in increased gene and in situ up‐regulation of proangiogenic factors (e.g., placental growth factor, hypoxia‐inducible factor‐1 alpha, and vascular endothelial growth factor), increased blood vessel formation (p<0.05), and enhanced wound closure (p<0.01) as compared with control dressings (without copper) or commercial wound dressings containing silver. This study proves the capacity of copper oxide‐containing wound dressings to enhance wound healing and sheds light onto the molecular mechanisms by which copper oxide‐impregnated dressings stimulate wound healing.     

Diagnosis and management of major vascular injuries: a review of 200 operative cases.

In a series of 250 civilian vascular injuries, 85 per cent were due to firearms and 50 per cent involved the torso, both of which represent an increased frequency of occurrence over other reports. There were 40 deaths, 31 of which occurred during operation or in the recovery room and were due to irreversible shock or coagulopathy. Of the nine late deaths, failure of the vascular repair was responsible for only three. In 124 extremity artery injuries, there were 12 leg amputations (10%) with shotgun wounds responsible for nine and popliteal artery injuries involved in seven. In gunshot wounds of the aorta and iliac arteries, there were five suture line disruptions in nine primary repairs and no disruptions in 11 patients repaired by grafts. The evidence indicates that an antibiotic soaked dacron graft is the method of choice to repair gunshot wounds of the aorta and iliac arteries at this time.     

Injuries of the inferior vena cava.

Injuries of the IVC, whether caused by blunt or penetrating mechanisms, are usually fatal. Patients who arrive in shock and fail to respond to initial resuscitative measures, those who are still actively bleeding at the time of laparotomy, and those with wounds of the retrohepatic vena cava have a low probability of survival. Death most commonly is caused by intraoperative exsanguination. Knowledge of the anatomy and exposure techniques for the five different segments of the intra-abdominal vena cava is very important to trauma surgeons. Although some wounds of the vena cava, especially those of the retrohepatic vena cava, are best left unexplored, most injuries inferior to this level can be exposed and repaired by lateral suture technique. Preservation of a lumen of at least 25% of normal is probably important in the suprarenal vena cava but is of no provable value inferior to the renal veins. No evidence supports the need to expose and repair vena caval wounds that have spontaneously stopped bleeding. Such wounds, especially in the retrohepatic area, may be managed expectantly provided that there is no strong suspicion of an associated injury to a major artery or hollow viscus.     

Successful Treatment of GSW to the Intrapericardial Inferior Vena Cava wall: Case Report

IntroductionPenetrating traumas to the thorax could be potentially serious. Vena caval wounds are highly lethal, so that half of the patients die before reaching the hospital, and another 50% may die perioperatively. Although rare, most of them are the result of gunshot wounds.Presentation of caseWe report a 13-year-old boy shot by an air gun through his right hemithorax. During surgery, an air gun bullet appeared right within the wall of the intrapericardial inferior vena cava (IVC).DiscussionTraumas to the thoracic contents as vena cava are inevitable, presenting mostly with haemo or pneumothorax. If the victim reaches the operating room alive, the approach to his or her vena cava rupture remains a challenge in the hands of surgeons.In this case, the surgeon, following the bullet removal, repaired the penetration immediately by direct suturing because clamping the inferior vena for its thin wall can expand the rupture, also blocking systemic venous return.ConclusionThe surgeon in a general trauma center that is almost lacking cardiopulmonary pump can repair the vital injuries to the IVC with the technique of direct suturing.     

PRIMARY REPAIR FOR COLONIC GUNSHOT WOUNDS

Background: Penetrating injuries of the colon have been managed traditionally by diverting colostomy. Recently, a trend towards primary repair has been observed, particularly for knife injuries. The purpose of this study is to evaluate the safety of primary repair for colonic gunshot wounds in the presence of certain clinical risk factors. Methods: A retrospective analysis of 223 patients with colonic bullet injuries in a period of 3 years (1990–93) was performed. Results: Of 223 patients with colonic trauma, 168 were primarily repaired (group A) and 55 underwent a colostomy (group B). Intra-abdominal septic complications occurred in 5.9% of group A patients and 10.9% of group B patients (P > 0.05, NS). These patients were, furthermore, stratified according to well-known risk factors for the development of complications, namely, site of injury, presence of shock on admission, degree of faecal contamination and number of associated injuries. We were unable to find any statistically significant differences in intra-abdominal septic complication rates between patients treated with primary repair and patients treated with colostomy. Conclusions: Primary repair seems to be a safe therapeutic option for gunshot wounds of the colon. Even in the presence of the abovementioned risk factors, colostomy may be avoided in most cases as primary repair does not appear to be associated with higher complication rates.     

Venous injury: to repair or ligate, the dilemma

Surgical management of major venous injuries remains controversial. The medical records of 184 patients with major venous injury were reviewed. Forty-three patients had isolated venous injury; 31 of 43 patients (72%) underwent ligation to treat their vein injury. Another 141 patients had combined arterial and venous injury; 117 of these patients (83%) had ligation. Injured were the inferior vena cava, iliac, femoral, popliteal, distal leg, and arm veins; all patients underwent surgical exploration. Arterial injuries were repaired by standard techniques and venous injuries were either ligated or repaired by end-to-end or lateral phleborrhaphy. Adjunctive fasciotomy was used when clinically indicated. The patients were followed up for 1 month to 9 years. No permanent sequelae of venous ligation were identified. Transient extremity edema developed in up to 32% of patients, regardless of whether vein ligation or repair was performed. This edema resolved completely within 12 weeks of the injury. No extremity was lost after ligation of a venous injury. Although it may be ideal to repair all venous vascular injuries, selective management reflecting mechanism of injury, blood loss, anesthesia requirements, associated organ injury, and other concerns may mitigate against extensive venous repair.     

Lower extremity vascular trauma: a comprehensive, aggressive approach

During this study, 25 patients (26 limbs) incurred 37 vascular injuries to the lower extremity. The majority were young males injured by penetrating trauma (84%). There were 25 arterial and 12 venous injuries (two isolated). Sixteen patients had soft-tissue injuries, 12 had fractures, and six had peroneal nerve damage. Twenty-two arterial injuries were repaired, the majority (17) by saphenous vein bypass. Three tibial vessels were ligated. All major venous injuries were repaired. No synthetic material was used. Vascular repair took precedence in all but two cases. After repair, the vascular surgeon assisted with stabilization. Thirteen limbs required fasciotomy; nine required subsequent debridements and later plastic reconstruction. Limb salvage was 96%. More important, 21 patients can ambulate independently on the injured extremity (84%). These results support an aggressive approach to lower extremity vascular trauma with repair of all major arterial and venous injuries in conjunction with aggressive debridement and soft-tissue repair.     

New approach to wounds of the aortic bifurcation and inferior vena cava

An approach to the repair of injuries of the bifurcation of the inferior vena cava and aorta is presented. This method involves division of the right common iliac artery with mobilization of the aorta for exposure of wounds to the confluence of the common iliac arteries as well as of the posterior wall of the distal aorta. Wide exposure of this area allows for more rapid control of bleeding vessels in addition to more precise vascular repair.     

Heparin inhibits fibrin, but not leukocytes, in a model of deep-vein thrombosis

Previous studies with models of deep-vein thrombosis (DVT) have demonstrated that leukocyte (PMN)-mediated vein injury may be an initiating event in DVT (14, 17). Since heparin (H) can prevent DVT, we studied its effect on vascular injury and thrombosis in our model. Three groups of rabbits were treated with H either sc (73 and 147 U/kg) or iv (662 U/kg). Scanning electron microscopy revealed that the 73 U/kg sc dose was ineffective. All veins had PMN accumulation, fibrin deposition and complex thrombus formation. There was no increase in anti-Xa activity; activated partial thromboplastin times (APTT) and whole blood clotting times were normal. The 147 U/kg sc and the intravenous dose did not inhibit PMN-mediated vein injury. The endothelium was sloughed by migrating PMNs, basement membrane was exposed, and platelets adhered to it. Thrombosis was completely absent in the iv dose group. This correlated with increased anti-Xa activity and prolonged APTT and whole blood clotting times. Our results indicate that heparin does not inhibit the PMN adhesion and migration which produces vascular injury. However, the anticoagulant activity of heparin effectively reduces fibrin deposition and complex thrombus formation.     

Abdominal vascular trauma: a review of 106 injuries.

A retrospective analysis of acute abdominal vascular injuries was performed to review outcome variables and treatment principles. The authors review their most recent 5-year experience with 106 major abdominal vascular injuries in 64 patients treated at a combined Army and Air Force urban medical center. The majority of the patients were young men who sustained penetrating injuries. There were 41 (64%) gunshot wounds, 17 (27%) stab wounds, and 6 (9%) sustained blunt trauma. Forty-five patients (71%) came to the hospital in shock. The inferior vena cava in 26 patients (41%) and the aorta in 11 patients (17%) were injured most frequently. Suture repair was possible in 53 (50%) injuries. Ligation was performed in 41 (39%). Overall mortality for the series was 39 per cent. Hemorrhagic shock was the cause of death in 23 patients (92%) with only two late deaths. Transfusion requirement, presence of shock, and number of vessels injured all affected outcome. Immediate stabilization in the emergency department includes appropriate crystalloid and blood product resuscitation with minimal delay for diagnostic studies. Prompt abdominal exploration to control hemorrhage and particular attention to factors associated with coagulopathy remain the key elements in saving the lives of these severely injured patients.     

Repair of bone defect with vascularized tissue engineered bone graft seeded with mesenchymal stem cells in rabbits

This study evaluated the results of repair of the radius defect with a vascularized tissue engineered bone graft composed by implanting mesenchymal stem cells (MSCs) and a vascular bundle into the xenogeneic deproteinized cancellous bone (XDCB) scaffold in a rabbit model. Sixty-four rabbits were used in the study. Among them, four rabbits were used as the MSCs donor. Other 57 rabbits were divided into five groups. In group one (n = 9), a 1.5 cm bone defect was created with no repair. In group two (n = 12), the bone defect was repaired by a XDCB graft alone. In group three (n = 12), the defect was repaired by a XDCB graft that included a vascular bundle. In group four (n = 12), the defect was repaired by a XDCB graft seeded with MSCs. In group five (n = 12), the defect was repaired by a XDCB graft including a vascular bundle and MSCs implantation. The rest three rabbits were used as the normal control for the biomechanical test. The results of X-ray and histology at postoperative intervals (4, 8, and 12 weeks) and biomechanical examinations at 12 weeks showed that combining MSCs and a vascular bundle implantation resulted in promoting vascularization and osteogenesis in the XDCB graft, and improving new bone formation and mechanical property in repair of radius defect with this tissue engineered bone graft. These findings suggested that the vascularized tissue engineered bone graft may be a valuable alternative for repair of large bone defect and deserves further investigations.     

Management of traumatic vascular injuries to the neck: a 7-year experience at a Level I trauma center

Injury to the carotid artery results in significant mortality and morbidity. The general consensus is to repair all injuries to the common and internal carotid arteries. Ligation is usually reserved for neurologic or hemodynamic instability. We report our experience at a Level I trauma center with vascular injuries to the neck. Retrospective chart review of all patients with vascular injuries in the neck resulting from either blunt or penetrating trauma treated at a Level I trauma center between January 2000 and February 2007. Demographics and outcomes were collected from a chart review. Twenty-five patients with vascular injuries to the neck were identified. There were 13 carotid artery injuries (CAI), five internal jugular vein (IJV) injuries, and 13 external jugular vein (EJV) injuries. Of the carotid artery injuries, six (50%) underwent operative repair (4 primary repairs and 2 bypasses), five (38%) were managed nonoperatively, and one was treated using endovascular techniques. No patient had a postoperative decrease in Glasgow Coma Scale score. There were five isolated IJV injuries (3 primary repair and 2 ligations). Four of the venous injuries (all internal jugular veins) were repaired and the remaining 13 were ligated. Vascular injuries to the neck have significant mortality and morbidity. Treatment of these injuries must be individualized. All CAI in noncomatose patients should be repaired if hemodynamically stable. All IJV injuries should be repaired but may be ligated if hemodynamically unstable. All EJV injuries can be ligated without reservation regardless of neurological status.     

火器性四肢组织缺损的显微外科修复

目的 对四肢组织缺损进行修复与功能重建。方法 自１９７９年以来,采用显微外科,修复与重建外多种新术式,对８００例四肢战伤性皮肤,肌肉,骨骼,血管及神经损伤进行修复与功能重建。结果 对３０例战作骨缺损,采用吻合血管的骨移植,全部获得成功,对１５０例周围神经火器伤,采用神经束间缝合及束间移植术,其总优良率传统方法为优;对５００例周围血管火器伤,早期进行血管吻合和血管移植术,血管通畅率为９１％,对１２０     

Management of small artery vascular trauma.

This 11-year retrospective study reviewed 99 arterial injuries distal to the brachial bifurcation or popliteal trifurcation in 89 extremities in 88 patients. Associated injuries occurred in 78 of 88 (89%) patients, including 10 fractures or dislocations, 66 nerve injuries, and 59 single or multiple tendon injuries. Fasciotomy was performed in 9 upper extremities and 11 lower extremities (23% of patients). The selection of operative treatment by arterial repair or ligation was by surgeon choice (52% repair and 48% ligation). Postoperative patency was found in 45 of 47 (96%) repaired arteries. In cases of isolated single arterial injuries (10), there were excellent results, and there was no difference in the results between repair and ligation. In cases of nonisolated single arterial injuries (69), there were 46% and 36% nonvascular complications in the repaired and ligated groups, respectively. In 10 patients with nonisolated multiple arterial injuries in the same extremity, the results of repair of one artery with ligation of the other artery versus repair of both arteries were identical, and there were no vascular complications. Operative exploration was the key to complete evaluation of vascular and neuro/musculoskeletal injuries. The data suggest that one functional artery distal to the elbow or knee is sufficient for limb viability and vascular function (follow-up range: 0 to 110 months; mean: 12 months). Nerve injury was the single most important factor of extremity injury in terms of the degree of functional loss.     

Coverage of acute vascular injuries of the axilla and groin with transposition muscle flaps: case reports

Acute axillary or groin vascular injuries caused by farm machinery or shotgun blasts are often associated with extensive soft-tissue loss. Coverage of the repaired blood vessels with healthy tissue is necessary to avoid infection, desiccation, pseudoaneurysm, and rupture. Adjacent muscles are not always available to rotate for coverage, due to unacceptable functional loss, or injury to the principal vascular pedicle. We used proximally based trunk musculature with vascular pedicles out of the areas of injury to achieve coverage of four extensive axillary wounds and one extensive groin wound. Arterial repair only was performed in three axillary wounds. Combined arterial and venous repair were performed in one groin wound and one axillary wound. Followup ranging from 9 months to 5 years revealed no vascular failure or soft-tissue complications. We conclude that coverage of vascular repairs and soft-tissue defects with viable muscle is necessary in cases of extensive injury. Adjacent muscle is preferred for coverage, but when this is unavailable, coverage can still be achieved using more proximally pedicled muscles of the trunk.     

The potential utility of fibrin sealant dressing in repair of vascular injury in swine

BACKGROUND: A previous study in which fibrin sealant dressing (FSD) secured hemostasis in major arterial hemorrhage for 96 hours suggested the applicability of this dressing in damage control operations after severe trauma. The objective of this study was to determine the effective duration of FSD hemostatic function in vivo and to examine its potential utility for definitive repair of a major arterial injury in swine. METHODS: High pressure bleeding in an infrarenal aortotomy was controlled by placing FSD on the wound with 4-minute compression (n = 15). If hemostasis was achieved, the abdominal cavity was closed. Surviving animals were killed at 2, 4, 6, and 8 weeks and aortotomy sites collected for histology. RESULTS: FSD stopped arterial hemorrhage after 4-minute compression in 14 of 15 (93%) pigs. Dressings failed in two pigs at 36 and 53 minutes after treatment. Twelve (80%) animals recovered and resumed normal activities. Of the remaining 12, two developed rebleeding at the aortotomy site on days 8 and 11 and were killed; another was killed because of idiopathic low hematocrit on day 10. Nine pigs survived until scheduled to be killed, maintaining hemostasis with stable hematological values. In the surviving animals, serial computed tomography scans showed formation of a pseudoaneurysm at the aortotomy site, which resolved after 2 to 3 weeks. The initial vascular defect and pseudoaneurysm were filled with fibroblast-myoblast collagen rich tissues covered by endothelium. CONCLUSION: FSD can seal an arterial injury, stop high pressure bleeding, and prevent rebleeding for at least 7 days. The dressing may be most beneficial in damage control operations. If combined with an elective interventional radiologic procedure (e.g. embolization or stenting), it may also offer an alternative to suture repair of vascular injuries in cases where profuse bleeding obstructs visualization.     

Utility of arteriography in penetrating extremity injuries

The role of contrast arteriography in the management of patients with penetrating injuries of the extremities is a subject of active debate. To examine our experience, the charts of patients with penetrating injuries of the extremities were retrospectively reviewed. Data from 82 consecutive patients with 98 wounds over the 5-year period from January 1984 to December 1988 were reviewed. Sixty-five arteriograms were obtained to investigate 98 wounds: 8 to localize a clinically apparent wound and 57 because of proximity of the wound or the trajectory of the injuring agent to a major neurovascular bundle. Of the 57 arteriograms obtained because of proximity, 11 identified a vascular injury (19%). Six of these wounds required vascular repair; five patients were treated expectantly. Six of the eight arteriograms obtained for clinical indications were positive (75%), while two were negative (25%). There were no amputations in the study, and all vascular reconstructions were considered successful by clinical and vascular laboratory criteria. One patient died of thoracic injuries; otherwise, all patients were discharged in good condition. Long-term follow-up was not available. In summary, 19% of arteriograms done because of proximity criteria alone identified a clinically occult vascular injury. While only 11% of all proximity arteriograms revealed injuries requiring surgical repair, this rate of significant injury warrants aggressive use of proximity arteriography in a patient population that is prone to poor follow-up.