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Objective: Acute limb ischemia (ALI) due to thromboembolism is a limb-and life-threatening condition regularly encountered by vascular surgeons. Iatrogenic distal embolization is occasionally seen as a complication of various endovascular procedures. We present a series of four patients who developed ALI due to arterial embolization during cardiovascular procedures that were successfully treated via catheter directed aspiration embolectomy. Methods: Retrospective review of demographics, risk factors, and procedural outcomes was completed for 4 patients who presented with ALI due to distal embolization following cardiovascular procedures. All patients were successfully treated with catheter directed aspiration embolectomy using the Penumbra Indigo System (Penumbra Inc., Alameda, California). All patients had high-quality angiography demonstrating successful embolectomy and end-procedure patency. Results: Three patients presented with Rutherford 2A and one with Rutherford 2B ALI secondary to intraoperative distal embolization. Three patients presented with ALI secondary to distal embolization during peripheral vascular interventions, and one following emergent intra-aortic balloon pump (IABP) placement for myocardial infarction. All emboli were located in the infra-inguinal vasculature. Median post-operative ABIs were 0.94 (n = 4). Median length of stay was 2 days. There were no mortalities and no need for adjunctive fasciotomy, amputation, or bypass for limb salvage. All patients improved clinically after intervention, and returned to their reported pre-hospitalization functional status. Conclusion: All procedures achieved technical success with catheter-directed aspiration thrombectomy with or without adjunctive lysis. Catheter-directed aspiration embolectomy with the Penumbra Indigo System for ALI following an iatrogenic embolic event is a safe, less-invasive treatment option. The use of this technology may reduce the need for traditional open thrombectomy or thrombolytic therapy to address ALI.

Background Current screening criteria miss 30% of blunt cerebrovascular injuries (BCVIs). Motor vehicle collisions (MVCs) are the leading BCVI mechanism, and delineating MVC characteristics associated with BCVI formation may augment current screening criteria. Methods We retrospectively identified BCVI Denver injury screening criteria as able from the Crash Injury Research and Engineering Network (CIREN) database. Severe MVC markers were considered: mean change in velocity (delta-v) greater than 40 km/hour, steering wheel airbag deployment, ejection, or rollover. Results 93 BCVIs were included. Injury screening criteria were not present in 37/93 (39.8%) BCVIs. Vertebral BCVI more often had injury screening criteria than internal carotid BCVIs (73.2% vs 26.8%, P = .001). There was a significant difference in delta-v (30.78 km/hour vs 51.00 km/hour, P < .001) between BCVI with and without injury screening criteria. BCVI without injury screening criteria more often had safety device use through seatbelt position snug across the hips (94.6% vs 74.5%, P = .01) and pretensioner deployment (92.6% vs 70.2%, P = .04). Examining only drivers, BCVI without injury screening criteria more often had steering wheel airbag deployment (89.7% vs 68.9%, P = .05). Markers of severe MVC were seen in 36/37 (97.3%) BCVIs without injury screening criteria. Discussion BCVI without injury screening criteria occurred during higher deceleration MVCs with more frequent/appropriate safety device use, suggesting crash deceleration as a mechanism of BCVI formation. Expanding BCVI screening criteria to encompass severe MVCs may lessen the number of BCVI missed.

Thirty-four patients were identified with repaired BTAI as previously described. All endografts were oversized by 0.05 (group 2, F 2,30 ¼ 2.58; P > .05). Maximum injury diameter was significantly different in group 1 before and after CT scans (t 20 ¼ 2.09; P < .05) but not in group 2 (t 19 ¼ 0.93; P ¼ .36) explained by one technical error. Preoperative healthy aortic diameters were significantly different from endograft size in group 1 (F 2,45 ¼ 15.74; P < .00001) and became nonsignificant on follow-up (F 2,41 ¼ 0.81; P > .05). Group 2 showed no difference between healthy aortic diameter and endograft size both preoperatively (F 2,35 ¼ 3.17; P > .05) and postoperatively (F 2,33 ¼ 0.76; P > .05) but trended toward significance.Conclusions: Exclusion of BTAI with TEVAR appears to promote early aortic remodeling. There was no evidence of residual aortic injury in technically successful repairs. Follow-up imaging suggests that injured aorta regresses to the diameter of the implanted endograft whereas healthy aorta dilates to the endograft. This further supports the theory that endografts serve as a bridge to aortic healing in BTAI and long-term seal is not necessary.

Objective: Emergent vascular surgery is often performed in patients transferred from one hospital to another for definitive surgical care; however, outcomes in this population have not been reported. In this study, we compared morbidity and mortality in patients presenting for emergent vascular surgery in the transferred and nontransferred populations.Methods: A retrospective analysis of prospectively collected data was performed using the National Surgical Quality Improvement Program database for all nonelective, emergent vascular surgery procedures performed between 2011 and 2014. Demographics, comorbidities, and 30-day complications and outcomes were compared between patients presenting from home and those presenting from another hospital or nursing home. Multivariate analysis was performed to determine the association between mode of presentation and major complications.Results: There were 14,831 patients identified; 9060 (61%) presented from home, and 5771 (39%) presented as a transfer from another hospital or a nursing home. Patients presenting in transfer were older (70 vs 67 years; P < .001), less likely to be diabetic (24% vs 30.2%; P < .001) or to be dialysis dependent (6.1% vs 9%; P < .001), and more likely to smoke (36.9% vs 32.5%; P < .001) or to have chronic obstructive pulmonary disease (16.7% vs 12%; P < .001). There was no difference in history of congestive heart failure (5.8% vs 5.7%; P ¼ .82). Patients presenting for surgery in transfer had increased rates of postoperative morbidity including pulmonary complications (22.0% vs 13.5%; P < .001), stroke (2.7% vs 1.8%; P < .001), urinary tract infection (3.9% vs 2.8%; P < .001), and bleeding requiring transfusion (48.1% vs 33.9%; P < .001). Mortality in the transfer group was significantly increased (15.6% vs 10.4%; P < .001). These differences persisted in multivariate analysis (Table ).Conclusions: Patients transferred from an outside hospital or nursing home who present for emergent vascular procedures demonstrate increased morbidity and mortality compared with those who present from home directly to the emergency department despite fewer comorbid conditions. Further study of transfer protocols and establishing guidelines for best practice in emergency vascular surgery are needed to improve outcomes for this population.