Abstract:

Background: mortality in polytrauma with pelvic injuries and intrapelvic bleeding remains high and can be reduced through a multidisciplinary approach to hemostasis.

Aim: was to determine possibilities and tactics of using endovascular interventions to stop intrapelvic bleeding in polytrauma with pelvic injuries.

Material and methods: a search was made for scientific articles in the PubMed database and the Scientific Electronic Library (eLIBRARY.ru), published from 2017 to 2021. Transcatheter embolization of pelvic arteries is an effective method for stopping intrapelvic bleeding and is indicated for detecting extravasation of contrast in computed tomography and angiography. In patients with unstable hemodynamics, embolization can be used if it is possible to perform it no later than 30-60 minutes after the detection of intrapelvic bleeding. Resuscitation endovascular balloon occlusion of the aorta can serve as an important component of the damage control strategy and a bridge to the application of methods for the final control of abdominal and intrapelvic bleeding in patients with unstable hemodynamics and systolic blood pressure less than 70 mm hg.

Conclusion: methods of endovascular surgery do not oppose and do not exclude the use of extraperitoneal pelvic packing and/or external fixation of the pelvis to stop intrapelvic bleeding in case of polytrauma. The choice of methods of hemostasis and the algorithm for their application are determined by the degree of hemodynamic disturbances, the presence of combined injuries, the data of radiation diagnostics, and the technical and logistical resources of the trauma center.

Abstract:

Introduction: pseudo-aneurysm of subclavian artery is a rare pathology and most often develops due to trauma or iatrogenic causes. Despite the rarity of this pathology, it can be accompanied by the risk of lethal rupture or distal embolism. Article presents a case report of endovascular treatment of post-traumatic pseudo-aneurysm of right subclavian artery with a stent-graft.

Aim: was to demonstrate advantages of endovascular treatment of pseudo-aneurysms, based on case report of patient with post-traumatic pseudo-aneurysm of right subclavian artery.

Material and methods: a case report of a patient with post-traumatic pseudo-aneurysm of right subclavian artery, polytrauma and pulmonary embolism is presented.

Results: successful endovascular treatment of pseudo-aneurysm of right subclavian artery with the implantation of stent-graft was performed. Postoperative period was uneventful, and the patient was discharged with improved health.

Conclusions: endovascular treatment is the preferred method, due to its less invasiveness and lower complication frequency in comparison with open surgery.

Abstract:

Background: pulmonary embolism (PE), is one of the most common cardiopulmonary pathologies in the world, has a high risk of developing after major operations on the osteoarticular system. Mortality from PE remains high, ranking third after myocardial infarction and stroke.

Aim: was to identify tomographic signs of PE in patients with osteoarticular pathology in the postoperative period.

Materials and methods: we analyzed results of computed angiopulmonography of 11 patients with suspicion on pulmonary embolism who were operated on osteoarticular pathology at the Federal Center for Traumatology, Orthopedics and Endoprosthetics of the Ministry of Health of the Russian Federation (Cheboksary). Patients showed such indirect signs of PE as discshaped atelectasis of lung tissues, expansion of diameter of pulmonary trunk and right pulmonary artery, signs of congestion in pulmonary circulation and pulmonary hypertension. Direct radiological signs included occlusion of a branch of pulmonary artery by thrombus.

Results: in 91% of examined patients, occlusion of branch of pulmonary artery by thrombus was detected, in 82% of cases - the defeat of branches of right pulmonary artery. Embolism at the level of lobar arteries was detected in 30%, segmental branches - in 60% of patients; signs of pulmonary embolism of one of subsegmental branches of right pulmonary artery - in one patient (10%). Bilateral thrombosis was observed in two patients, including massive bilateral PE in one case. One patient had discoid atelectasis of lung tissues. Expansion of diameter of pulmonary trunk and right pulmonary artery was observed in 78% of patients with PE, signs of congestion in pulmonary circulation - in 27% of cases, pulmonary hypertension - in 73% of cases.

Conclusion: visualization of direct and indirect signs of pulmonary embolism during computed pulmonary angiography confirmed the diagnosis in all examined patients. The detection of blood clots in pulmonary arteries themselves is the main criterion in making the final diagnosis.

References

1.     Nikolaev NS, Trofimov NA, Kachaeva ZA, et al. Prevention and treatment of pulmonary thromboembolism in traumatology and orthopedics. Tutorial. Cheboksary: Publishing house of the Chuvash University, 2020; 108 [In Russ].

2.     Krivosheeva EN, Komarov AL, Shakhnovich RM, et al. Clinical analysis of a patient with antiphospholipid syndrome and submassive pulmonary embolism. Aterotromboz. 2018; (1): 76-87 [In Russ].

https://doi.org/10.21518/2307-1109-2018-1-76-87

3.     Hepburn-Brown M, Darvall J, Hammerschlag G. Acute pulmonary embolism: a concise review of diagnosis and management. Internal Medicine Journal. 2019; 49(1): 15-27.

https://doi.org/10.1111/imj.14145

4.     Ostapenko EN, Novikova NP. Pulmonary embolism: modern approaches to diagnosis and treatment. Ekstrennaya meditsina. 2013; 1(5): 84-110 [In Russ].

5.     Sinyukova AS, Kiseleva LP, Kupaeva VA. A clinical case of recurrent pulmonary embolism and the complexity of the diagnostic search. Sovremennaya meditsina: aktual'nye voprosy. 2015; (42-43): 24-31 [In Russ].

6.     Bagrova IV, Kukharchik GA, Serebryakova VI, et al. Modern approaches to the diagnosis of pulmonary embolism. Flebologiya. 2012; 6(4): 35-42 [In Russ].

7.     Kuznetsov AB, Boyarinov GA. Early diagnosis of pulmonary embolism (review). Sovremennye tekhnologii v meditsine. 2016; 8(4): 330-336 [In Russ].

8.     Bershteyn LL. Pulmonary embolism: clinical manifestations and diagnosis in the light of the new recommendations of the European Society of Cardiology. Kardiologiya. 2015; 55(4): 111-119 [In Russ].

https://doi.org/10.18565/cardio.2015.4.111-119

9.     Sakharyuk AP, Shimko VV, Tarasyuk ES, et al. Pulmonary embolism in clinical practice. Byulleten' fiziologii i patologii dykhaniya. 2015; (55): 48-53 [In Russ].

10.   M Al-hinnawi A-R. Computer-Aided Detection, Pulmonary Embolism, Computerized Tomography Pulmonary Angiography: Current Status. Intech Open. 2019; 19.

http://doi.org/10.5772/intechopen.79339

11.   Gilyarov MYu, Konstantinova EV. How do new approaches to the treatment of pulmonary embolism affect disease outcome? Meditsinskiy sovet. 2017; (7): 48-55 [In Russ].

https://doi.org/10.21518/2079-701X-2017-7-48-55

12.   Konstantinides S. Guidelines on the diagnosis and management of acute pulmonary embolism. The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur. Heart J. 2014; (35): 3033-3080.

13.   Tagalakis V, Patenaude V, Kahn SR, Suissa S. Incidence of and mortality from venous thromboembolism in a real-world population: the Q-VTE Study Cohort. Am J Med. 2013; 126(832): 13-21.

https://doi.org/10.1016/j.amjmed.2013.02.024

Abstract

Background: ongoing abdominal and pelvic bleeding is one of main causes of deaths among patients with penetrating and blunt trauma. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a method for temporary patient's stabilization and reducing blood loss.

Aim: was to present result of work of 1st-level trauma-center: to describe experience of application of methodics of REBOA in center, to estimate its efficacy on the base of retrospective analysis of hospital charts of injured and heavy damaged patients.

Materials and methods: during the period between April 2013 and November 2017, 14 REBOA procedures to patients with abdominal (thoracic aorta occlusion) and pelvic (occlusion of the aortic bifurcation) bleeding were performed at the War Surgery Department of the «KirovMilitaryMedicalAcademy». A decision to do REBOA was made upon admission according to significant hypotension (systolic blood pressure [sBP] less than 70 mm Hg.) or cardiac arrest, abdominal free fluid and/or mechanically unstable pelvic fractures.

Results: mean time from admission to REBOA was 27,5 [10,0-52,5] minutes. The procedure took 10 [5-13] minutes. Average BP elevation after balloon inflation was 43±16 mm Hg. Survival in acute phase of trauma (first 12 hours) was 57.1%, while total survival rate was only 14.3% (2/14 patients). One REBOA-associated major complication was registered - development of irreversible ischemia due to long sheath dwell time in the femoral artery.

Conclusion: REBOA is effective for temporary hemodynamic stabilization and internal hemorrhage control, it allows increasing early survival in severe trauma. Factors to improve short- and long-term outcome, total survival warrant to be additionally investigated, especially in terms of intensive care improvement.

References

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2.     Barnard E.B.G., Morrison J.J., Madureira R.M. et al. Resuscitative endovascular balloon occlusion of the aorta (REBOA): a population based gap analysis of trauma patients in England and Wales. Emerg. Med. J. 2015; 32 (12): 926-932.

3.     Brenner M.L., Moore L.J., DuBose J.J. et al. A clinical series of resuscitative endovascular balloon occlusion of the aorta for hemorrhage control and resuscitation. J. Trauma Acute Care Surg. 2013; 75 (3): 506-511.

4.     Moore L.J., Brenner M., Kozar R.A. et al. Implementation of resuscitative endovascular balloon occlusion of the aorta as an alternative to resuscitative thoracotomy for resuscitative balloon occlusion of the aorta (REBOA). J. Trauma Acute Care Surg. 2016; 81 (3): 409-419.

5.     Zavrazhnov A.A. Damage of large vessels of the abdomen: ways to improve diagnosis and treatment: Diss. kand. med. Nauk. St.Petersburg. 1996; 201 [In Russ].

6.     Sadeghi M., Nilsson K.F., Larzon T. et al. The use of aortic balloon occlusion in traumatic shock: first report from the ABO trauma registry. Eur. J. Trauma Emerg. Surg. 2018; 44 (4): 491-501.

7.     Hughes C.W. Use of an intra-aortic balloon catheter tamponade for controlling intra-abdominal hemorrhage in man. Surgery. 1954; 36 (1): 65-68.

8.     DuBose J.J., Scalea T.M., Brenner M. et al. The AAST prospective Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry: Data on contemporary utilization and outcomes of aortic occlusion and resuscitative balloon occlusion of the aorta (REBOA). J. Trauma Acute Care Surg. 2016; 81 (3): 409-419.

9.     Martinelli T., Thoni F., Declety P. et al. Intra-aortic balloon occlusion to salvage patients with life-threatening hemorrhagic shocks from pelvic fractures. J. Trauma. 2010; 68 (4): 942-948.

10.   Brenner M., Hoehn M., Pasley J. et al. Basic endovascular skills for trauma course: bridging the gap between endovascular techniques and the acute care surgeon. J. Trauma Acute Care Surg. 2014; 77 (2): 286-291.

11.   DuBose J., Fabian T., Bee T. et al. Contemporary utilization of resuscitative thoracotomy: results from the AAST aortic occlusion for resuscitation in trauma and acute care surgery (AORTA) multicenter registry. Shock. 2018; 50 (4): 414-420.

12.   Gumanenko E.K. An objective assessment of the severity of injuries. Voenno-medicinskij zhurnal. 1996; 317 (10): 25-34 [In Russ].

13.   Samokhvalov I.M., Reva V.A., Pronchenko A.A., Agliulin V.F. Comparison of the effectiveness of emergency thoracotomy in wounded and injured. Zdorov'e. Medicinskaja jekologija. Nauka. 2012; 1-2 (47-48): 43 [In Russ].

14.   White J.M., Cannon J.W., Stannard A. et al. Endovascular balloon occlusion of the aorta is superior to resuscitative thoracotomy with aortic clamping in a porcine model of hemorrhagic shock. Surgery. 2011; 150 (3): 400-409.

15.     Ogura T., Lefor A.T., Nakano M. et al. Nonoperative management of hemodynamically unstable abdominal trauma patients with angioembolization and resuscitative endovascular balloon occlusion of the aorta. J. Trauma Acute Care Surg. 2015; 78 (1): 132-135

Abstract:

Background: we present a literary review of foreign articles on the strategy of treating of patients with blunt abdominal trauma and/or pelvic fractures, without laparotomic access using endovascular diagnosis and treatment.

Aim: was to analyze the modern approach in the diagnosis and treatment of arterial bleeding Г patients with blunt abdominal trauma and/or pelvic fractures according to literary sources. Materials and methods: article reviewed 3 studies, 1 literary review of articles by foreign authors and guidelines of the Eastern Association of Traumatology

Results: computed tomography with contrast enhancement was the method of choice for diagnosing blunt abdominal trauma and pelvic fractures, endovascular treatment of arterial hemorrhage has proven its effectiveness and is increasingly included in routine practice in both hemodynamically stable patients and patients with unstable hemodynamics.

Conclusion: catheter embolization for arterial bleeding can be used as monotherapy or as a stage of stabilizing the patient before open surgical treatment.

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Abstract:

Background: the cause of the development of traumatic hernias of the diaphragm is its damage due to open or closed injury In modern conditions, the diaphragm injury is most common trauma in falling from height and car accidents (multiple trauma), and can be unnoticed in againts the background of other injuries.

The dislocation of abdominal organs into the pleural cavity occurs in various, sometimes long, time periods after trauma. This situation is determined by the gradual increase in the size of the defect due to the difference in pressure in the abdominal and pleural cavities.

Aim: was to study the importance of radiodiagnosis of traumatic hernias of the diaphragm.

Materials and methods: two rare clinical cases of traumatic diaphragmatic hernias are presented. In one observation - a woman of 81 years, in the second - a 66 years old man. Results: a woman with a history of trauma as a result of a car accident 10 years ago, basec on a comprehensive survey, revealed posttraumatic hernia of the right half of the diaphragm with a dislocation into the pleural cavity of the small and large intestine.

In the second case report (male), an old rupture of the left half of the diaphragm of unknowr prescription of injury was revealed with the dislocation of the greater part of the intestine and the left kidney

Conclusion. To diagnose traumatic hernias of the diaphragm, a comprehensive examination of patients is necessary. Plain radiography can detect the dislocation of abdominal organs into the pleural cavity, and examination of the gastrointestinal tract with a water-soluble contrast drug is a violation of the passage.

Multi-slice computed tomography (MSCT) in case of such pathology, has a greater importance, because thin sections give the highest resolving power. The construction of multiplanar reformation allows obtaining more complete information on the dislocation of organs, visualizing the defect of the diaphragm and determining its exact localization.

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15.    Akar E., Kaya H. Traumatic rupture of the diaphragm: A 22-patient experience. Biomedical Research. 2017; 28 (20): 8706-8710.

16.    Mikheev A.V., Trushin S.N., Bazzaev T.M. i dr. Ushchemlennaia pravostoronniaia travmaticheskaia diafragmalnaia gryzha [Strangulated right-sided traumatic diaphragmatic hernia.]. Al'manakh instituta khirurgii im. A.V. Vishnevskogo. 2017; 2: 148-149 [In Russ].

17.    Plaksin S.A., Kotelnikova L.P Dvustoronnie posttravmaticheskie diafragmalnye gryzhi [Two-sided post-traumatic diaphragmatic hernia.]. Vestnik khirurgii im. 1.1. Grekova. 2015; 174 (1): 47-51 [In Russ].

18.    Gali B.M., Bakari A.A., Wadinga D.W., Nganjiwa U.S. Missed diagnosis of a delayed diaphragmatic hernia as intestinal obstruction: a case report. Niger J Med. 2014; 23 (1): 83-85.

19.    Demuro J.P A delayed traumatic diaphragmatic hernia presenting with a bowel obstruction 20 years postinjury. J Clin Diagn Res. 2013; 7(4): 736-738. doi: 10.7860/JCDR/2013/4755.2898.

20.    De Nadai T.R., Lopes J.C., Inaco Cirino C.C. et al. Diaphragmatic hernia repair more than four years after severe trauma: Four case reports. Int J Surg Case Rep. 2015; 14: 72-76. doi: 10.1016/j.ijscr.2015.07.014.

21.    Wadhwa R., Ahmad Z., Kumar M. Delayed traumatic diaphragmatic hernia mimicking hydropneumothorax. Indian J Anaesth. 2014; 58 (2): 186-189. doi: 10.4103/ 0019-5049.130825.

22.    Falidas E., Gourgiotis S., Vlachos K., Villias C. Delayed presentation of diaphragmatic rupture with stomach herniation and strangulation. Am J Emerg Med. 2015; 33 (9): 1329. e1-3. doi: 10.1016/j.ajem.2015.02.052.

23.    Gao J.M., Du D.Y, Li H. et al. Traumatic diaphragmatic rupture with combined thoracoabdominal injuries: Difference between penetrating and blunt injuries. Chin J Traumatol. 2015; 18 (1): 21-26.

24.    Liao C.H., Chu C.H., Wu YT. et al. The feasibility and efficacy of laparoscopic repair for chronic traumatic diaphragmatic herniation: introduction of a novel technique with literaturereview. Hernia. 2016; 20 (2): 303-309. doi: 10.1007/s10029-015-1405-2.

Abstract:

Arm. In order to improve the quality of severe pelvis fractures' diagnostics, detection of pelvic organs' lesion, preoperative examination and monitoring of treatment, we have made a retrospective analysis of radiological data of 70 patients (46 males, 24 females) aged between 24 and 54 years who were treated in emergency departments of hospital.

Results. The diagnostic efficiency of X-rays for injuries of the pelvis in case of lesions of the acetabulum is less than MDCT (specificity - 70.4%, accuracy - 61.3%, sensitivity - 56.3%). At the same time, traditional X-rays should only be used to diagnose fractures without displacement and for the control of metal after the surgery It is established that multidetector CT is the method of choice and the first stage in the diagnosis of associated injuries and hidden pelvic fractures, and has the best indicators of diagnostic value (specificity - 69% accuracy - 95% predictive of a positive result - 90%).

Conclusion. It was established that radiography is a method of screening and monitoring of treatment in patients with injuries of the pelvic ring and acetabulum, and in the first place during the provision of urgent specialist care. However, existing X-ray examination methods are not sufficiently informative, particularly in the diagnosis of posterior half-ring damage and hip; early and complete radiodiagnostics of pelvic and intrapelvic organs' injures is the leader in terms of examination of patients. A differentiated approach to the assessment of individual semiotic signs of pelvic fractures with MSCT improves informative value not only from the standpoint of initial diagnostics, but also helps to predict possible complications.

References 

1.     Gumanenko E.K., Shapovalov V. M., Dulaev A.K., Dudykin A.V. Sovremennye podhody k lecheniju postradavshih s nestabil'nymi povrezhdenijami tazovogo kol'ca. [Current approaches to the treatment of patients with unstable pelvic ring injuries] Voenno-med. zhurnal. 2003; 4: 17. [In Russ].

2.     Ratnikov V.A. SYNGO-MR-tehnologija: metodika i vozmozhnosti vizualizacii organov brjushnoj polo- sti i taza na vysokopol'nom (1,5 T) magnitnom tomografe «MAGNETOM SYMPHONY» [SYNGO- MR-Technology: methodology and visualization of the abdomen and pelvis in the 1.5 T magnetic tomography «MAGNETOM SYMPHONY»]. ( V.A. Ratnikov, G.E. Trufanov, S.V. Serebrjakova). Materialy Nevskogo radiologicheskogo foruma «Iz buduwego v nastojawee». SPb, 2003; 343 [In Russ].

3.     Balogh Z., Voros E., Suveges G. Stent graft treatment of an external iliac artery injury associated with pelvic fracture. A case report. J. Borne Joint Surg. Am. 2003; 5: 919-922.

4.     Serebrjakova S.V. Spiral'naja komp'juternaja tomografija v diagnostike povrezhdenij vertluzhnoj vpadiny (S.V. Serebrjakova, V. M. Cheremisin, O. F. Pozdnjakova) [Spiral computed tomography in the diagnosis of acetabulum lesions]. Materialy Nevskogo radiologicheskogo foruma «Iz buduwego v nastojawee». SPb, 2003; 113-115 [In Russ].

5.     Djatlov M. M. Luchevaja diagnostika povrezhdenij tazovogo kol'ca v ostrom periode perelomov vert- luzhnoj vpadiny. [Radiological diagnosis of pelvic ring injuries in acute acetabular fractures]. Ortop., travm im Priorova 2003; 3: 72-74 [In Russ].

6.     Miller P. R, Moore P. S., Mansell E., Meredith J. W. С External fixation or arteriogram in bleeding pelvic fracture: initial therapy guided by. Clin. Imaging. 2003; 18(4): 533-536.

7.     Loberant N., Goldfeld M. A pitfall in triple contrast CT of penetrating trauma of the flank. Clin. Imaging. 2003; 27(5): 351-352.

8.     Tile M. Fracture of pelvis. The Rationale of operative Fracture Care. Spinger Verlag. 1987: 441.

Abstract:

Aim: was to increase efficacy of diagnostics of oculomotor muscles injury in pre- and postoperative period with use of multislice computed tomography (MSCT).

Material and methods: for the petiod 2015-2016, 63 patients with maxillofacial trauma were admitted to the I.M.Sechenov hospital, within 24-48 hours after injury (55 males and 8 females, aged 18-59 years). All patients underwent MSCT of facial skeleton at the day of admittion and on 7-10 day after surgical treatment. Patients examination was made on 640-slice CT scanner and was added by multiplannar and 3D-reconstruction

Results: preoperative MSCT revealed oculomotor muscles injury in 29 patients (46%). Muscles injuries were presented with herniation into the maxillary sinus (n=20, 32%), damaged lateral, inferior and medial muscles by small bone fragments (n=17, 27%), unilateral thickening of muscles in 13 patients (21%).

Postoperative MSCT revealed oculomotor muscle damage caused by incorrectly implantation of prostheses of inferior orbital wall in 7 cases (11%).

Conclusion: MSCT is the modality of choice in pre- and postoperative diagnostics in patients with oculomotor muscles injury. MSCT provides the effective diagnostic solution in prevention of possible ocular movement impairment.  

References 

1.    Natsional’nie rukovodstva po luchevoi diagnostike i terapii (pod red.S.K.Ternovogo). [National guidance of radiology and radiotherapy. (Ed. By S.K. Ternovoy)] М.: GEOTAR- Media, 2013; 1000S. [In Russ].

2.    Nikolaenko V.P., Astakhov Yu.S. Orbital’nie perelomi: rukovodstvo dlya vrachei [Orbital fractures: guidance for the clinicians.] St. Petersburg: Eco-Vector; 2012; 303-328 [In Russ].

3.    Serova N.S. Luchevaya diagnostika sochetannikh povrezhdeniy kostey litsevogo cherepa i orbiti. [Radiodiagnostics of complex trauma of facial skeleton and orbit.] Cand. Diss. О. 2006 [In Russ].

4.    Pavlova O.Yu, Serova N.S. Protokol multispiral’noi komp’uternoi tomografii v diagnotike travm srednei zoni litsa. [MSCT diagnostic protocol in trauma of mid-face.] REJR 2016; 6(3):48-53. [In Russ].

5.    Chupova N.A. Funktsional’naya multispiralnaya komp’uternaya tomografia v otsenke mishts glaza pri mehanicheskom povrezhdenii. [Functional multislice computed tomography in assessment of oculomotor muscles within trauma.] Cand. Diss. М. 2013; 141S. [In Russ].

6.    Pavlova O.Y., Serova N.S. Mnogosrezovaya komp’uternaya tomografia v diagnostike perelomov glaznits. [Multislice computed tomography in the diagnosis of orbital fractures.] Journal of radiology. 2015; 3:12-17 [In Russ].

7.    Stuchilov V.A., Nikitin A.A. Optimizatsia diagnostiki I hirurgicheskogo lechenia bol’nikh pri perelomakh glaznits. Posobie dlya vrachei [Optimization of diagnostics and surgical treatment in orbital fractures. Guidance for the clinicians.] М.: 2015, 36S. [In Russ].

8.    Mikhaylyukov V.M., Davidov D.V., Levchenko O.V. Posttravmaticheskie defekti I deformatsii glaznitsi. Osobennosti diagnostiki I printsipi lechenia (obzor literaturi). Golova I sheya. [Posttraumatic orbital defects and deformations. Diagnostics features and treatment principles (literature review). Head and neck.] Rossijskoe izdanie. Zhurnal Obsherossijskoi obshestvennoi organizatsii «Federatsia spetsialistov po lecheniyu zabolevaniy golovi I shei». 2013; 2: 40-48 [In Russ].

9.    Wayne S. Kubal. Imaging of Orbital Trauma. RadioGraphics. 2008; 28:1729-1739.

10.  Nastri A.L., Gurney B. Current concepts in midface fracture management. Curr Opin Otolaryngol Head Neck Surg. 2016; 24(4):368-75.

Abstract:

Aim: was to assess the efficacy of surgical treatment of post-traumatic arteriovenous fistula with use of stent-grafts.

Materials and methods: stent-grafts were successfully used in treatment of 4 patients with post-traumatic arteriovenous fistula (AVF). In 2 cases AVF were located in iliac vessels, in 1 case in shin and in 1 case - thigh. In 3 cases, appearance of AVF was a result of gunshot wound, in 1 case - stab wound

Results: technical success was achieved in all cases. In 1 case after endovascular elimination of AVF on the level of iliac vessels, retroperitoneal hematoma with infection was revealed, that leaded to open surgical operation.

Conclusion: the use of stent-grafts in surgical correction of vessel injury can decrease operational trauma, and can achieve better clinical results and good long-term prognosis.  

References

1.    Petrovskij B.V., Milonov O.B. Hirurgija anevrizm perifericheskih sosudov [Surgery of peripheral vessels' aneurysms] M.: Medicina. 1970; 273S [In Russ].

2.    Kugukarslan N.L., Oz B.S., Ozal E.,Yildirim V., Tatar H. Factors affecting the morbidity and mortality of surgical management of vascular gunshot injuries: missed arterial injury and disregarded vein repair. Ulus Travma Acil Cerrahi Derg. 2007;13(1):43-48.

3.    Gavrilenko A.V. Travmaticheskie arteriovenoznye svishhi [Traumatic arteriovenous fistula]. OAO «Izdatel'stvo «Medicina» Klinicheskaja angiologija: Ruk. pod red. A.V. Pokrovskogo. 2004;2: 340-344 [In Russ].

4.    Gavrilenko A.V., Egorov A.A. Tradicionnaja hirurgija sosudov i rentgenjendovaskuljarnye vmeshatel'stva - konkurencija ili vzaimodejstvie, vedushhee k gibridnym operacijam? [Traditional sugery of vessels versus endovascular treatment: competition or cooperation, leading to the hybrid operation?] Angiologija i sosudistaja hirurgija. 2011; 17(4):152-156 [In Russ].

5.    Zotov S.P., Shherbakov A.V., Kugeev A.F., Zajcev S.S., Shakirov R.G., Semashko T.V., Zhabreev A.V., Panov I.O. Klinicheskie osobennosti posttravmaticheskih arterio- venoznyh svishhej [Clinical features of post-traumatic arteriovenous fistula]. Angiologija i sosudistaja hirurgija. 2011; 17(2):133-137 [In Russ].

6.    Li F., Song X., Liu C., Liu B., Zheng Y Endovascular stent-graft treatment for a traumatic vertebrovertebral arteriovenous fistula with pseudoaneurysm. Ann. Vasc. Surg. 2014; 2:489.

7.    Mensel B., Kuhn J.P, Hoene A., Hosten N., Puls R. Endovascular repair of arterial iliac vessel wall lesions with a self-expandable nitinol stent graft system. PLoS One. 2014; 9(8): journal.pone.0103980.

8.    Park H.K., Choe W.J., Koh YC., Park S.W. Endovascular management of great vessel injury following lumbar microdiscectomy. Korean J. Spine. 2013; 4:264-267.

9.    Sin'kov M.A., Murashkovskij A.L., Pogorelov E.A., Golovin A.A., Kalichenko N.A., Haes B.L., Kokov A.N., Heraskov V.Ju., Evtushenko S.A., Popov V.A., Barbarash L.S. Sluchaj uspeshnogo jendovaskuljarnogo zakrytija jatrogennogo arterio-venoznogo soust'ja podvzdoshnoj arterii i veny, projavljajushhegosja venoznym trombojembolicheskim sindromom i pravozheludochkovoj nedostatochnost'ju [Successful endovascular occlusion of iatrogenic arteriovenous fistula of the iliac artery and vein with thromboembolic syndrome and right ventricular insufficiency]. Diagnosticheskaja i intervencionnaja radiologija. 2014; 8(2):98-102 [In Russ].

Abstract:

The research is devoted to study the possibilities of functional multislice computed tomography (fMSCT) in a choice of treatment strategy, its planing and volume of surgical intervention at orbital trauma damage. MSCT and fMSCT examinations of the orbit were performed in 30 patients (60 orbits).

The obtained data allowed to develop the protocol of fMSCT, to study normal functional anatomy of the eye, to estimate normal contractile ability of extraocular muscles. The research showed the necessity of using the fMSCT of the eye of orbital trauma in assessment of contractile ability of extraocular muscles and their interest in relation to the crisis area. The improvement of diagnosis reached with the help of fMSCT, has allowed to choose an optimum tactics and volume of surgical intervention.  

References 

1.    Слободин К.Э. Лучевая диагностика по вреждений глаз. СПб. 2007.

2.    Красильников Р.Г., Варуск С.В., Жупан Б.Б. Возможности использования компьютерной и магнитнорезонансной томографии в диагностике повреждений орбит и глаза и их осложнений. Современные аспекты военной медицины. Киев. 2007; 12: 16–24.

3.    Александров Н.М., Аржанцев П.3. Травмы челюстнолицевой области. М. 1986.

4.    Слободин К.Э. Принципы, современные возможности и перспективы лучевой диагностики в офтальмологической практике. М. Вестник рентгенологии и радиологии. 2001; 1: 55–61.

5.    Бровкина А.Ф. Болезни орбиты. М. 2008.

6.    Бабий Я.С., Болгова И.М., Удовиченко В.В. Лучевые методы диагностики при заболеваниях глаза и орбиты. М. Вестник Российского научного центра рентгенологии. 2004; 3.

7.    Труфанов Г.Е., Бурлаченко Е.П. Лучевая диагностика заболеваний глаза и глазницы. СПб. 2009.

8.    Бровкина А.Ф., Яценко О.Ю., Мослехи Ш. и др. Оценка корреляции данных КТ и УЗИ при исследовании толщины экстраокулярных мышц у больных отечным экзофтальмом. М. Клиническая офтальмология. 2008; 2: 61.

9.    Бровкина А.Ф., Яценко О.Ю., Аубакирова А.С., Мослехи Ш. Компьютернотомографическая анатомия орбиты с позиции клинициста. Вестник офтальмологии. 2008; 124 (1): 11–14.

10.  Ozgen A., Ariyurec M. Normative measurements of orbital structures using CT. Am. J. Roentgenol. 1998; 170 (4): 1093–1096.

11.  Furuta M. Measurement of orbital volume by computed tomography. Еspecially on the growth of the orbit. Jpn. J. Ophthalmol. 2001; 45 (6): 600–606.

12.  Demer J.L., Miller J.M. Magnetic Resonance Imaging of the Functional anatomy of the Superiror Oblique Muscle. Investigative Ophthalmology & Visual Science. 1995; 36 (5): 209–913.

13.  Horton J.C. et al. Magnetic resonance imaging of superior oblique muscle atrophy in acquired trochlear nerve palsy [letter].

14.  Am. J. Ophthalmol. 1990; 110: 315–316.

15.  Koo E.Y. et al. MRI demonstrates normal contractility of superior rectus (SR) and inferior rectus (IR) in orbits with hypertropia. Ophthalmology. 1993; 100 (9A): 119.

Abstract:

Aim. Was to study X-ray computer tomography (X-CT) semiotics of lungs injure in patients with closed thoracic trauma.

Materials and methods. For the period of 2008-2009 in Moscow Institute of Emergency First Aid we have examined 90 patients with different forms of pulmonary hemorrhage: aged 15-83 years (middle age 33,8); 71 men (78,9%) and 19 women (21,1%).The diagnosis was established due to X-CT

Results. All the patients had pulmonary bruise with different Intensity and prevalence on the 1st day In 67% patients it was combined with bleeding or/and gas in the depth of lungs - hematoma, hemopneumatocele, pneumatocele. Supervision in dynamics showed gradually regression of bruise lesions and traumatic caverns structure transformation

Conslution. X-CT in patients with closed thoracic trauma can specify the localization, characteristic and volume of pulmonary injure; it can also document pathologic process in dynamics.
 

References 

1.      Ермолов А.С. Основные принципы диагностики и лечения тяжелой сочетанной травмы. 80 лекций по хирургии. Под ред. В.С.   Савельева.   М.:   Литтерра.   2008;507-514

2.      Collins J. Chest wall trauma. J. Thorac. Imaging. 2000; 15: 112-119.

3.      Miller D.L., Mansour K.A. Blunt traumatic lung injuries. Thorac. Surg. Clin. 2007; 17: 57-61.

4.      Неотложная лучевая диагностика механических повреждений. Руководство для врачей. Под ред. В.М. Черемисина, Б.И. Ищен-ко. С.-Пб.: Гиппократ. 2003; 448.

5.      Marts B. et al. Computed tomography in the diagnosis of blunt thoracic injury. Am. J. Surg. 1994; 168: 688-692.

6.      Wanek S., Mayberry J.C. Blunt thoracic trauma. Flail chest, pulmonary contusion and blast injury. Crit. Care. Clin. 2004; 20: 71-81.

Abstract:

In order to check the efficiency of pharmacological prophylaxis of venous thromboembolism in 500 patients with multiple injuries we weekly performed ultrasonography of lower limb veins from 3-5 days after the accident date. Patients were divided into two groups. There were 186 patients with prophylaxis with LMWH in the first group, other group included 314 patients which took single antiplatelet therapy. Thrombosis occured in 29 (15.6%) cases in the first group. In 19 (61.2%) limbs thrombosis defeated the common femoral vein and it was floating in 67.7% of cases. In the second group thrombosis was found in 165 (52.5%) patients. Mural (46%) and occlusive (35.3%) changes from the proximal border, not reaching the common femoral vein - (62%) were dominating.

It was found that during fraxiparine treatment venous complications were 3.3 times less likely than with antiplatelet agents, however, 3.6 times increased the proportion of floating embologenic thrombosis. However, in these patients, the spread of the pathological process in the proximal direction noted in 2 times less, and the beginning of recanalization 1-2 weeks earlier and more effective restoration of the lumen.

References

1.     Van Hensbroek P.B., Haverlag R., Ponsen K.J. et al., Prevention of thrombosis in traumatology. Ned. Tijdschr. Geneeskd.2007; 4(151): 234-239.

2.     Lippi G., Franchini M. Pathogenesis of venous thromboembolism: when the cup runneth over. Semin Thromb Hemost. 2008; 8(34):747-761.

3.     Baeshko A.A. Risk i profilaktika venoznykh tromboembolicheskikh oslozhnenii v khirurgii [Risk and prophylaxis of venous thromboembolic complications in surgery] Khirurgiya. 2001; 4: 61-67 [In Russ].

4.     Anderson F.A., Spencer F.A. Risk factors for venous thromboembolism. Circulation. 2003;107: 33-38.

5.     Geerts W.H., Jay R.M., Code K.I. et al. A comparison of low-dose heparin with low-molecular-weight heparin as prophylaxis against venous thromboembolism after major trauma. N. Engl. J. Med. 1996; 335: 701-707.

6.     Lazarenko V.A., Mishustin V.N. Pulmonary artery thromboembolism in patients with trauma. Angiol. Sosud. Khir. 2005; 11(4): 101-104.

7.     Geerts W.H., Pineo G.F., Heit J.A. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004; 126(3): 338-400.

8.     Giannadakis K., Leppek R., Gotzen L. et al. Thromboembolism complication in multiple trauma patients: an underestimated problem? Results of a clinical observational study of 50 patients. Chirurg. 2001;72:100-107.

9.     Knudson M.M., Lewis F.R., Clinton A. et al. Prevention of venous thromboembolism in trauma patients. J. Trauma. 1994; 37:11-15.

10.   Rogers F.B. Venous thromboembolism in trauma patients: a review. Surgery. 2001;130:74-78.

11.   Kearon, C. Natural history of venous thromboembolism. Circulation. 2003;107(1):22-30.

12.    Robinson D.M., Wellington K. Fondaparinux sodium: a review of its use in the treatment of acute venous thromboembolism. Am. J. Cardiovasc. Drugs. 2005; 5: 335-346.

13.    Shchelokov A.L., Zubritskii V.F., Nikolaev K.N i dr. Kombinirovannaya venoznykh tromboembolicheskikh oslozhnenii u postradavshikh s perelomami proksimal'nogo otdela bedrennoi kosti [Combined prophylaxis of venous tromboembolic complications in patients with fracture of proximal part of femur]. Vestniktravmatologiii ortopedii. 2007;1:16-21 [In Russ].

14.    Asamov R.E., Tulyakov R.P., Muminov Sh.M. i dr. Bessimptomnye flebotrombozy nasledstvennaya trombofiliya u bol'nykh so skeletnoi travmoi [Asymptomatic phlebothrombosis and hereditary thrombophilia in patients with skeletal trauma]. Angiologiya i sosudistaya khirurgiya. 2008; 3:73-76 [In Russ].

15.    Kruger K., Wildberger J., Haage P. et al. Diagnostic imaging of venous disease: Part I: methods in the diagnosis of veins and thrombosis. Radiologe. 2008; 48 (10): 977-992.

16.    Tomkowski W.Z., Davidson B.L., Wisniewska J. et al. Accuracy of compression ultrasound in screening for deep venous thrombosis in acutely ill medical patients. Thromb. Haemost. 2007; 97(2):191-194.

17.    Savel'ev V.S. Venoznye trombozy i tromboemboliya legochnoi arterii (venoznye tromboembolicheskie oslozhneniya): Metod. rekomendatsii. V.S.Savel'ev [Venous trombosis and pulmonary embolism (venous tromboembolic complications )]. M., 2007: 20 s [In Russ].

18.    Balakhonova T.V. Sovremennye instrumental'nye metody diagnostiki tromboza: ul'trazvukovoe dupleksnoe skanirovanie. Profilaktika tromboembolicheskikh oslozhnenii v travmatologii i ortopedii [Modern instrumental diagnostics of trombosis: ultrasonic duplex scanning. Prophylaxis of thromboembolic complications in traumatology and orthopedics.]: materialy gor. simp., Moskva. 2003; 12-17 [In Russ].

19.    Utverzhdenie otraslevogo standarta vedeniya bol'nykh. Profilaktika tromboembolii legochnoi arterii pri khirurgicheskikh i inykh invazivnykh vmeshatel'stvakh: Prikaz Ministerstva zdravookhraneniya Rossiiskoi Federatsii №233 ot 09.06.2003 [Approval of medical treatment standarts. Prophylaxis of pulmonary embolism in surgical and other interventions: order of Ministry of Health of the Russian Federation №233 since 09.06.2003] [In Russ]. 

Abstract:

Successful endovascular occlusion of iatrogenic arteriovenous fistula of the iliac artery and vein with tromboembolic syndrome and right ventricular insufficiency, occurred after surgical intervention on spine (mircodiscectomy of L4-L5, decompression of L5 radix). Disease spreaded under clinic of tromboembolic syndrome with formation of arteriovenous fistula and manifested like thromboembolic syndrome with right ventricular insufficiency.

References

1.     Papadoulas S., Konstantinou D., Kourea H.P, et al. Vascular injury complicating lumbar disc surgery: a systematic review. Eur. J. Vasc. Endovasc. Surg. 2002; 24: 189-195.

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3.     Jarstfer B.S., Rich N.M. The challenge of arteriovenous fistula formation following disk surgery: a collective review. J. Trauma. 1976; 16: 726-733.

4.     Palmon S.C., Moore L.E., Lundberg J., Toung T. Venous air embolism: a review. J. Clin. Anesth. 1997; 9: 251-257.

5.     Goodkin R., Laska L.L. Vascular and visceral injuries associated with lumbar disc surgery: medicolegal implications. Surg. Neurol. 1998; 49: 358-372.

6.     Quigley T.M., Stoney R.J. Arteriovenous fistulas following lumbar laminectomy: the anatomy defined. J. Vasc. Surg. 1985; 2: 828-833.

7.     Jarstfer B.S., Rich N.M. The challenge of arteriovenous fistula formation following disk surgery: a collective review. J. Trauma. 1976; 16: 726-732.

8.     Ewah B., Calder I. Intraoperative death during lumbar discectomy. Br. J. Anaesth. 1991; 66: 721-723.

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10.   Epstein F.H., Post R.S., McDowell M. The effect of an arteriovenous fistula on renal hemodynamics and electrolyte excretion. J. Clin. Invest. 1953; 32: 233-241.

11.   McCarter D.H., Johnstone R.D., McInnes G.C., et al. Iliac arteriovenous fistula following lumbar disc surgery treated by percutaneous endoluminal stent grafting. Br. J. Surg. 1996; 83: 796-797.

12.   Burger T., Meyer F., Tautenhahn J., et al. Percutaneous treatment of rare iatrogenic arteriovenous fistulas of the lower limbs. Int. Surg. 1998; 83, 198-201. 

Abstract:

Acute traumatic aortic rupture is associated with extremely high mortality and requires urgent diagnosis and treatment.

Materials and methods: patient P, 33 years 28.12.2013, fall from a height of 5 floors. On the day of admittion to hospital he was hospitalized to the reanimation department with a diagnosis of «multiple trauma, traumatic shock». For nearest hours after admission MSCT of head, neck, chest organs, abdomen and pelvis were performed.

Results: in series of images of the head and neck revealed multiple fractures of facial bones anc skull base, hemo-sinus.

MSCT chest without contrast enhancement: expanding boundaries revealed the presence of the upper mediastinum content density of 65 Hounsfield units (Ed.N) around the arch and descending aorta, in tissues of the posterior mediastinum. Volume of about 35 cm3 - in the pericardial cavity, ribs on the left with a displacement of fragments, left-sided hemothorax (260 cm3). During examination of abdomen and pelvis in the native phase: in subhepatic space in the liver portal, volume of about 50 cm3 with density of blood multiple fractures of the pelvis. CT with contrast-enhanced bolus revealed uneven expansion in the thoracic aorta isthmus length of 60 mm, with the presence at this level of linear structures intraluminal wall surface (wall laceration), and a narrow zone of extravasation of the contrast agent on the inner contour of the aorta. At the lever portal detected delimited zone of active extravasation of contrast material as a result of breaking its proper hepatic artery which is essentially as a thrombosis of pseudoaneurysm with zone of thrombosis around the periphery and subcapsular rupture of the left lobe of the liver

Ultrasound examination - left-sided hydrothorax, echo signs of free fluid in the abdominal cavity, liver hematoma in the area of the portal, diffuse changes in kidneys («shock» kidney).

Patient underwent primary surgical dressing of face wounds, osteosynthesis of right femur with external fixation device (EFD). Endoprothesis of descending thoracic aorta was performed 29.12.2013. After implantation of the prothesis, celiacography was performed, in which in liver portal, in the place of proper hepatic artery division to the right and left hepatic artery - large-size false aneurysm was revealed.

CT scanning, performed on the 5th day after aortic replacement: there are signs of segmental atelectasis of the lower lobe of the left lung, minimum infiltrative changes in fiber anterior mediastinum, hematoma of the posterior mediastinum (31 cm3. Previously was 191 cm3), and hemopericardium (15 cm3 compared with 35 cm3)

In the process of dynamic observation, it was found that up to 30 days, false aneurysm of proper hepatic artery increased in size, in this regard, the patient was operated on 24.01.14.

Follow-up CT scan with contrast enhancement: branches of the hepatic artery are well visualized, artery aneurysm is not defined

12.02.14, was the dismantling of EFD and manufactured fixation of the right femur pin. After 65 days after the injury and the start of treatment the patient was discharged under the supervision of the surgeon and cardiologist in the community.

References

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Abstract:

In patients with severe multiple trauma, posttraumatic period is often complicated by the development of polyorgan insufficiency, development of which is connected with morpho-functional changes of the liver parenchyma.

Aim: was to identify dynamics of ultrasound signs of morphological and functional changes of liver in patients with multiple trauma.

Materials and methods: performed analysis of ultrasound data obtained in dynamics, in 28 patients with severe multiple trauma. From the analysis, we excluded patients with blunt abdominal trauma with injury of liver. In first 2 days, 21 patients underwent surgical operations in treatment of craniocerebral trauma and trauma of musculoskeletal system. All patients underwent ultrasound examination of the abdominal cavity and retroperitoneal space to exclude possibility of appearance of free liquid; also estimated condition of liver, spleen, functional and morphological condition of the gastrointestinal tract. In first days after trauma, ultrasound examination was performed 2-3 times. Color duplex scanning of vessels of liver and spleen was performed once a day or every other day for 2-3 weeks of a traumatic period. Evaluated arterial and venous blood flow of liver by measuring the linear blood flow velocity (LBFV) and resistance index (RI), portal blood flow by measurement of linear and volumetric flow rate.

Results: in all patients on admission to hospital, liver and spleen sizes had normal size. On the 3rd day after the injury, was revealed an increase in the cranio-caudal liver size by 2-4 cm and increased length of spleen by 5-8 cm, which lasts for 10-20 days. During dynamical ultrasound, 8 patients with 10-20 days against a background of increasing level of bilirubin and transaminases, in addition to increasing size of liver and spleen, we marked infiltration of tissues along hepatic veins with their narrowing and along branches of the portal vein with thickness from 0,25 to 0,7 cm. We marked LBFV decreasement by portal vein to 10-13 cm/sec and a volume flow to 250-400 ml / min, increased RI by hepatic artery In 3 patients in the liver parenchyma, we revealed avascular tissue regions with decreased echogenicity, indicating the formation of ischemic regions.

Conclusion: during dynamical ultrasound in patients with severe multiple trauma, on day 3 after injury, were diagnosed morphological changes in liver parenchyma with violation of its hemodynamics. Further progression of the process observed for 10-20 days from the date of trauma: the growth of intrahepatic portal hypertension, increased peripheral resistance in arteries of liver parenchyma, the appearance of ischemic areas of liver parenchyma. The totality of above ultrasonic signs of hemodynamic disorders of liver, characterize organic hepatocellular insufficiency, which is a poor prognostic sign in the development of polyorgan insufficiency.

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