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Brachial Artery Transection Secondary to Open Elbow Dislocation in an 11-Year-Old Girl
Journal of Vascular Surgery
Abstracts
855
Volume 64, Number 3 syndrome. Initial PMT combined with ongoing CDT can provide these outcomes. Up-and-over infusion catheters are a useful alternative to prograde popliteal access, reducing the likelihood of access site complications from compression in the popliteal veins after treatment. Author Disclosures: J. Worsham: None; C. Cheng: None; G. Fankhauser: None; Z. Cheema: None; M. Silva: Honoraria; Boston Scientific. Honoraria; My Role; Medical Advisory Board Member.
Extension-Distraction Injury of the Thoracolumbar Spine With Associated Traumatic Thoracic Aortic Injury: A Case Report Sandra Toth, BS, Doran Mix, MD, Roan Glocker, MD, Adam Doyle, MD, Michael Stoner, MD, and Jennifer Ellis, MD. University of Rochester Medical Center, Rochester, NY Objective: Traumatic thoracic aortic injury (TAI) is the second most common mechanism for traumatic death. Most TAIs are due to blunt trauma caused by rapid deceleration and flexion forces during automobile accidents. We present a unique case of extension-distraction injury to the thoracolumbar spine (TLS) associated with complete transection of the descending thoracic aorta. Methods: A 44-year-old woman presented after being struck by an automobile as a pedestrian. She was initially hemodynamically stable and arrived neurologically intact but within a few hours developed hypotension. Contrast-enhanced computed tomography images revealed complete transection of the descending thoracic aorta 2.3 cm above the celiac artery (Fig, A). Corresponding to the level of her vascular injury was a T11-T12 extension-distraction injury with disruption of anterior and posterior ligaments. Results: She was taken emergently to the operating room for thoracic endovascular aortic repair. Aortography confirmed active extravasation. A Gore CTAG graft (W. L. Gore & Associates, Flagstaff, Ariz) was advanced to the distal thoracic aorta and deployed over the site of injury, proximal to the celiac origin. Completion aortography demonstrated adequate seal of the aortic injury. She underwent spinal fusion the next day and was discharged to home 2 weeks later. One month after injury, she maintained full neurologic function, and contrast-enhanced computed tomography angiography images revealed no residual aortic injury (Fig, B). Conclusions: A rare association between blunt abdominal aortic injury and flexion-distraction injury of the TLS has been reported. To our knowledge, this is the second case reported of TLS extension-distraction injury with associated TAI.
Distraction injuries of the TLS due to hyperextension represent 3% of spinal fractures. Most are observed in patients with ankylosing conditions of the spine and are associated with a high incidence of paraplegia. Extension injuries involve a shear force causing ligamentous disruption beginning anteriorly and proceeding posteriorly. Weiss postulated that disruption of anterior spinal ligaments without injury to posterior ligaments suggests a hyperextension force of insufficient magnitude to cause aortic rupture. Our case supports this hypothesis, as aortic disruption was observed with disruption of both anterior and posterior ligaments, suggesting a more aggressive approach to screening for aortic injuries when both anterior and posterior ligaments are disrupted. Author Disclosures: S. Toth: None; D. Mix: None; R. Glocker: None; A. Doyle: None; M. Stoner: None; J. Ellis: None.
Brachial Artery Transection Secondary to Open Elbow Dislocation in an 11-Year-Old Girl Craig W. Milner, MD, Rafael D. Malgor, MD, and John Blebea, MD, MBA. The University of Oklahoma, Tulsa, Okla Objective: Open elbow dislocation causing brachial artery transection is a rare entity that can cause substantial morbidity, especially in children. We present a case of open elbow dislocation in a young girl who required brachial artery repair. Methods: On comprehensive review of the literature, only a few cases of pediatric brachial artery transection secondary to open elbow dislocation were identified. Primary arterial repair and interposition grafting are potential treatment options; however, size mismatch may preclude the latter in young patients. Little midterm follow-up with functional outcomes has been reported. Results: An 11-year-old girl sustained a left open elbow dislocation after falling from horseback, which caused a complete transection of her brachial artery. She was transferred to our regional trauma center after a 5-hour history of left forearm and hand ischemia. Protrusion of her left distal humerus was clearly seen through an open antecubital wound, and her distal left upper extremity was pulseless. The patient underwent expeditious left elbow reduction along with end-to-end brachial artery repair. To decrease tension on the arterial repair, the elbow joint was splinted at a fixed 70-degree angle in supinated position. In the immediate postoperative period, she had strong radial and ulnar pulses and her left forearm and hand compartments were soft. She was discharged on postoperative day 3 on a daily aspirin. At 6-month follow-up, she has been able to use her arm for most of her routine and leisure activities, such as playing the piano. She is currently receiving physiotherapy to increase muscle strength and to gain range of motion. Conclusions: Open elbow dislocation causing brachial artery transection is an uncommon injury, particularly in children. Direct brachial artery repair in the subset of patients with reduced-caliber vessels, limited conduit options, and prolonged hand ischemia can be expeditiously and safely performed with excellent midterm results. Author Disclosures: C. W. Milner: None; R. D. Malgor: None; J. Blebea: None.
Losing Exposure: Diminishing Revascularization Experience in General Surgery Residency Therese Federowicz, MD, Amber Trickey, PhD, Erica Emery, MS, Jonathan Dort, MD, and Dipankar Mukherjee, MD. INOVA Fairfax Medical Campus, Falls Church, Va
Fig. A, Thoracic aortic disruption (red arrow). B, Threedimensional reconstruction after thoracic endovascular aortic repair.
Objective: With the rising popularity of endovascular procedures, there is concern that vascular surgery trainees receive increasingly limited experience with open lower extremity revascularization procedures. The purpose of the study was to evaluate trends in open lower extremity revascularization procedures performed by general surgery residents and vascular surgery fellows over time. These trends were assessed alongside resident participation in endovascular revascularization procedures over time. Methods: The Accreditation Council for Graduate Medical Education case logs of general surgery residents and vascular surgery fellows were reviewed from 2005-2006 to 2014-2015. The mean numbers of open aortoiliac and infrainguinal revascularization cases per surgeon were compared by academic year. Case logs for endovascular revascularization procedures were available beginning in 2007-2008. Nonparametric tests for trend were performed to evaluate changes over time.
Abstracts
855
Volume 64, Number 3 syndrome. Initial PMT combined with ongoing CDT can provide these outcomes. Up-and-over infusion catheters are a useful alternative to prograde popliteal access, reducing the likelihood of access site complications from compression in the popliteal veins after treatment. Author Disclosures: J. Worsham: None; C. Cheng: None; G. Fankhauser: None; Z. Cheema: None; M. Silva: Honoraria; Boston Scientific. Honoraria; My Role; Medical Advisory Board Member.
Extension-Distraction Injury of the Thoracolumbar Spine With Associated Traumatic Thoracic Aortic Injury: A Case Report Sandra Toth, BS, Doran Mix, MD, Roan Glocker, MD, Adam Doyle, MD, Michael Stoner, MD, and Jennifer Ellis, MD. University of Rochester Medical Center, Rochester, NY Objective: Traumatic thoracic aortic injury (TAI) is the second most common mechanism for traumatic death. Most TAIs are due to blunt trauma caused by rapid deceleration and flexion forces during automobile accidents. We present a unique case of extension-distraction injury to the thoracolumbar spine (TLS) associated with complete transection of the descending thoracic aorta. Methods: A 44-year-old woman presented after being struck by an automobile as a pedestrian. She was initially hemodynamically stable and arrived neurologically intact but within a few hours developed hypotension. Contrast-enhanced computed tomography images revealed complete transection of the descending thoracic aorta 2.3 cm above the celiac artery (Fig, A). Corresponding to the level of her vascular injury was a T11-T12 extension-distraction injury with disruption of anterior and posterior ligaments. Results: She was taken emergently to the operating room for thoracic endovascular aortic repair. Aortography confirmed active extravasation. A Gore CTAG graft (W. L. Gore & Associates, Flagstaff, Ariz) was advanced to the distal thoracic aorta and deployed over the site of injury, proximal to the celiac origin. Completion aortography demonstrated adequate seal of the aortic injury. She underwent spinal fusion the next day and was discharged to home 2 weeks later. One month after injury, she maintained full neurologic function, and contrast-enhanced computed tomography angiography images revealed no residual aortic injury (Fig, B). Conclusions: A rare association between blunt abdominal aortic injury and flexion-distraction injury of the TLS has been reported. To our knowledge, this is the second case reported of TLS extension-distraction injury with associated TAI.
Distraction injuries of the TLS due to hyperextension represent 3% of spinal fractures. Most are observed in patients with ankylosing conditions of the spine and are associated with a high incidence of paraplegia. Extension injuries involve a shear force causing ligamentous disruption beginning anteriorly and proceeding posteriorly. Weiss postulated that disruption of anterior spinal ligaments without injury to posterior ligaments suggests a hyperextension force of insufficient magnitude to cause aortic rupture. Our case supports this hypothesis, as aortic disruption was observed with disruption of both anterior and posterior ligaments, suggesting a more aggressive approach to screening for aortic injuries when both anterior and posterior ligaments are disrupted. Author Disclosures: S. Toth: None; D. Mix: None; R. Glocker: None; A. Doyle: None; M. Stoner: None; J. Ellis: None.
Brachial Artery Transection Secondary to Open Elbow Dislocation in an 11-Year-Old Girl Craig W. Milner, MD, Rafael D. Malgor, MD, and John Blebea, MD, MBA. The University of Oklahoma, Tulsa, Okla Objective: Open elbow dislocation causing brachial artery transection is a rare entity that can cause substantial morbidity, especially in children. We present a case of open elbow dislocation in a young girl who required brachial artery repair. Methods: On comprehensive review of the literature, only a few cases of pediatric brachial artery transection secondary to open elbow dislocation were identified. Primary arterial repair and interposition grafting are potential treatment options; however, size mismatch may preclude the latter in young patients. Little midterm follow-up with functional outcomes has been reported. Results: An 11-year-old girl sustained a left open elbow dislocation after falling from horseback, which caused a complete transection of her brachial artery. She was transferred to our regional trauma center after a 5-hour history of left forearm and hand ischemia. Protrusion of her left distal humerus was clearly seen through an open antecubital wound, and her distal left upper extremity was pulseless. The patient underwent expeditious left elbow reduction along with end-to-end brachial artery repair. To decrease tension on the arterial repair, the elbow joint was splinted at a fixed 70-degree angle in supinated position. In the immediate postoperative period, she had strong radial and ulnar pulses and her left forearm and hand compartments were soft. She was discharged on postoperative day 3 on a daily aspirin. At 6-month follow-up, she has been able to use her arm for most of her routine and leisure activities, such as playing the piano. She is currently receiving physiotherapy to increase muscle strength and to gain range of motion. Conclusions: Open elbow dislocation causing brachial artery transection is an uncommon injury, particularly in children. Direct brachial artery repair in the subset of patients with reduced-caliber vessels, limited conduit options, and prolonged hand ischemia can be expeditiously and safely performed with excellent midterm results. Author Disclosures: C. W. Milner: None; R. D. Malgor: None; J. Blebea: None.
Losing Exposure: Diminishing Revascularization Experience in General Surgery Residency Therese Federowicz, MD, Amber Trickey, PhD, Erica Emery, MS, Jonathan Dort, MD, and Dipankar Mukherjee, MD. INOVA Fairfax Medical Campus, Falls Church, Va
Fig. A, Thoracic aortic disruption (red arrow). B, Threedimensional reconstruction after thoracic endovascular aortic repair.
Objective: With the rising popularity of endovascular procedures, there is concern that vascular surgery trainees receive increasingly limited experience with open lower extremity revascularization procedures. The purpose of the study was to evaluate trends in open lower extremity revascularization procedures performed by general surgery residents and vascular surgery fellows over time. These trends were assessed alongside resident participation in endovascular revascularization procedures over time. Methods: The Accreditation Council for Graduate Medical Education case logs of general surgery residents and vascular surgery fellows were reviewed from 2005-2006 to 2014-2015. The mean numbers of open aortoiliac and infrainguinal revascularization cases per surgeon were compared by academic year. Case logs for endovascular revascularization procedures were available beginning in 2007-2008. Nonparametric tests for trend were performed to evaluate changes over time.