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BACKGROUND: Antibiotic resistance is an increasing concern for Emergency Physicians. OBJECTIVES: To examine whether empiric antibiotic therapy achieved appropriate antimicrobial coverage in emergency department (ED) septic shock patients and evaluate reasons for inadequate coverage. METHODS: Retrospective review was performed of all adult septic shock patients presenting to the ED of a tertiary care center from December 2007 to September 2008. Inclusion criteria were: 1) Suspected or confirmed infection; 2) ≥ 2 Systemic Inflammatory Response Syndrome criteria; 3) Treatment with one antimicrobial agent; 4) Hypotension requiring vasopressors. Patients were dichotomized by presentation from a community or health care setting. RESULTS: Eighty-five patients with septic shock were identified. The average age was 68 ± 15.8 years. Forty-seven (55.3%) patients presented from a health care setting. Pneumonia was the predominant clinically suspected infection (n = 38, 45%), followed by urinary tract (n = 16, 19%), intra-abdominal (n = 13, 15%), and other infections (n = 18, 21%). Thirty-nine patients (46%) had an organism identified by positive culture, of which initial empiric antibiotic therapy administered in the ED adequately covered the infectious organism in 35 (90%). The 4 patients who received inadequate therapy all had urinary tract infections (UTI) and were from a health care setting. CONCLUSION: In this population of ED patients with septic shock, empiric antibiotic coverage was inadequate in a small group of uroseptic patients with recent health care exposure. Current guidelines for UTI treatment do not consider health care setting exposure. A larger, prospective study is needed to further define this risk category and determine optimal empiric antibiotic therapy for patients.

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The authors report the microbiology and outcomes following an individualized treatment algorithm for extracavitary (EC) prosthetic graft infection, including the use of graft preservation and in situ graft replacement techniques. A retrospective 8-year review of 87 patients treated for EC prosthetic graft infections was carried out. The treatment algorithm included culture-specific antibiotic therapy, surgical site debridement with antibiotic bead placement, selected graft preservation with muscle flap coverage, or graft excision with in situ conduit replacement. Outcomes measured included death, limb loss, and recurrent infection. It was found that present-day management of EC prosthetic graft infections is associated with lower mortality and morbidity despite changes in microbiology and the increased application of graft preservation and in situ grafting treatments.

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BACKGROUND/PURPOSE: This study analyzes the safety and efficacy of carotid angioplasty/stenting (CAS) with embolic protection devices in high surgical risk (HSR) patients. PATIENT POPULATION/METHODS: This study includes 100 consecutive HSR patients, who were followed prospectively, and had carotid duplex ultrasounds at 1 month and every 6 months thereafter. A Kaplan-Meier lifetable analysis was used to estimate survival rates, rates of freedom from stroke, and freedom from > or =50% in-stent restenosis. RESULTS: Mean age was 69.6 years. There were 59 men and 41 women. Mean follow-up was 26.1 months (range, 1-50). Indications for CAS were symptomatic > or =50% stenosis in 47% and > or =80% asymptomatic stenosis in 53%. Procedure success rate was 100%. HSR includes 33% with restenosis and cardiac comorbidity, 21% with restenosis and cardiac/medical comorbidities, 13% with restenosis only, and 33% with cardiac/medical comorbidities. The 30-day perioperative stroke rate was 2% with no perioperative deaths or MI. Stroke-free survival rates were 95%, 91%, 83%, 79%, and 73% at 1, 2, 3, and 4 years, respectively. There were no late strokes. Stroke-free rate was 98% at 1, 2, 3, and 4 years, respectively. Freedom from > or =50% in-stent restenosis was 98%, 93%, 90%, and 79% at 1, 2, 3, and 4 years, respectively. Six patients had asymptomatic > or =80% in-stent restenosis; 3 underwent reintervention (percutaneous transluminal angioplasty). The incidence of in-stent restenosis was not statistically significant between patients who had restenosis after carotid endarterectomy and patients with primary stenting (P = .21). CONCLUSIONS: CAS with embolic protection devices in HSR patients is safe and effective.

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BACKGROUND: Several studies have reported that carotid endarterectomy with patch angioplasty is superior to primary closure. Conventional polytetrafluoroethylene (Gore-Tex, W. L. Gore & Associates, Flagstaff, Ariz) patching has been shown to have results similar to autogenous saphenous vein patching; however, it requires a longer hemostasis time. This study examined the long-term clinical outcome and incidence of restenosis after carotid endarterectomy using the new ACUSEAL (Gore-Tex) patching vs Hemashield Finesse (Boston Scientific Corp, Natick, Mass) patching. METHODS: The study randomized 200 patients (1:1) undergoing carotid endarterectomy to 100 with ACUSEAL patching and 100 with Hemashield-Finesse patching. All patients underwent immediate and 1-month postoperative duplex ultrasound studies, which were repeated at 6-month intervals. Kaplan-Meier analysis was used to estimate the freedom from stroke, stroke-free survival, and the risk of restenosis for both groups. RESULTS: The demographic and clinical characteristics, the mean operative diameter of the internal carotid artery, and the length of the arteriotomy were similar in both groups. The mean hemostasis time was 5.1 for the ACUSEAL patching vs 3.7 minutes for Finesse patching (P = .01); however, the mean operative times were similar for both groups (P = .61). The incidence of ipsilateral stroke was 2% for ACUSEAL patching (both early perioperative strokes) vs 3% for Finesse patching (2 early and 1 late stroke) at a mean follow-up of 21 months. The respective cumulative stroke-free rates at 1, 2, and 3 years were 98%, 98%, and 98% for ACUSEAL patching vs 97%, 97%, and 97% for Finesse patching (P = .7). The respective cumulative stroke-free survival rates at 1, 2, and 3 years were 97%, 92%, and 88% for ACUSEAL patching vs 96%, 96%, and 91% for Finesse patching (P = .6). The respective freedom from > or =70% carotid restenosis at 1, 2, and 3 years was 98%, 96%, and 89% for ACUSEAL patching vs 92%, 85%, and 79% for Finesse patching (P = .04). CONCLUSIONS: Carotid endarterectomy with ACUSEAL patching and Finesse patching had similar stroke-free rates and stroke-free survival rates. The mean hemostasis time for the ACUSEAL patch was 1.4 minutes longer than that for the Finesse patch; however, the Finesse patch had higher restenosis rates than the ACUSEAL patch.

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BACKGROUND: The preferential use of primary iliac stenting vs selective stenting is controversial. This study compares the early and late clinical outcomes of primary vs selective iliac stenting at our institution. METHODS: A total of 110 consecutive patients with iliac stenosis (149 lesions) underwent primary stenting over a recent 5-year period (primary stent group). The early technical and clinical success and late clinical outcomes were compared with 41 patients (41 iliac lesions) who had percutaneous transluminal angioplasty (PTA) followed by selective stenting for suboptimal PTA (selective stent group). All patients were evaluated clinically and by duplex scanning with ankle-brachial indexes at 1, 6, and 12 months and every 12 months thereafter. RESULTS: The perioperative complication rate for the primary stent group was 2.7% (three minor hematomas) vs 24% for the selective stent group (P < .0001). The overall early clinical success rate was 97% for the primary stent group vs 83% for the selective stent group (P = .002), however, the rate was 100% for short stenosis (A and B lesions <5 cm TASC classification) in both groups; in contrast to 93% for the primary stent group vs 46% for the selective stent group for longer stenoses (TASC - C and D lesions, P = .0003). The overall late clinical success was comparable for both groups: 88% for the primary stent group vs 80% for the selective stent group, however, this rate was superior for the longer lesions in the primary stent group, 84% vs 46% (P = .007). The primary patency rates at 1, 2, 3, and 5 years were 98%, 94%, 87%, and 77% for the primary stent group vs 83%, 78%, 69%, and 69% for the selective stent group (P = .030). These rates were comparable in both groups for shorter lesions: 100%, 98%, 98%, and 87% for the primary stent group vs 100%, 93%, 85%, and 85% for the selective stent group (P = .637). However, they were superior for the primary stent group in longer lesions: 96%, 90%, and 72% vs 46%, 46%, and 28% for the selective stent group at 1, 2, and 3 years (P < .0001). CONCLUSIONS: The overall early clinical success rate was superior for the primary stent group. However, the initial (early) and late clinical success rates were comparable for short lesions (TASC - A and B lesions), but were inferior in selective stenting for longer lesions (TASC - C and D). Therefore, primary stenting should be offered to all TASC - C and D lesions.

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Decompressive craniectomy to relieve cerebral edema and intracranial hypertension due to traumatic brain injury is a generally accepted practice; however, the procedure remains controversial because of its uncertain effects on outcome, specific complications such as the syndrome of the sinking skin flap, and the need for subsequent cranioplasty. The authors developed a novel craniotomy technique using titanium bone plates in a hinged fashion, which maintains cerebral protection while reducing postoperative complications and eliminating subsequent cranioplasty procedures. The authors conducted a retrospective review of data obtained in all consecutive patients who had undergone posttraumatic cerebral decompression craniotomy using the hinge technique at a Level I trauma facility between 1990 and 2004. Twenty-five patients, most of whom were male (88%) and Caucasian (88%) with a mean age of 38.2 +/- 16.1 years, underwent the hinge craniotomy. The in-hospital mortality rate was 48%, and good cerebral decompression was achieved. None of the patients required surgery for flap replacement. Long-term follow-up data showed that one patient required subsequent cranioplasty due to infection and one patient presented with cranial deformities. None of the patients presented with bone resorption or sinking flap syndrome. The hinge technique effectively prevents procedure-related morbidity and the need for subsequent surgical bone replacement otherwise introduced by traditional decompressive craniectomy. A randomized controlled trial is required to substantiate these findings.

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Carotid percutaneous transluminal angioplasty/stenting has become an accepted treatment modality for carotid artery stenosis in high-risk patients. There has been an ongoing debate regarding which duplex ultrasound (DUS) criteria to use to determine the rate of in-stent restenosis. This prospective study revisits DUS criteria for determining the rate of in-stent restenosis. In analyzing a subset of 12 patients (pilot study) who had both completion carotid angiography and DUS within 30 days, 10 patients with normal post-stenting carotid angiography (< 30% residual stenosis) had peak systolic velocities (PSVs) of the stented internal carotid artery (ICA) of < or = 155 cm/s and two patients with > or = 30% residual stenosis had internal carotid artery (ICA) PSVs of > 155 cm/s. Eighty-three patients who underwent carotid stenting as part of clinical trials were analyzed. All patients underwent post-stenting carotid DUS that was done at 1 month and every 6 months thereafter. PSVs and end-diastolic velocities of the ICA and common carotid artery were recorded. Patients with PSVs of the ICA of > 140 cm/s underwent carotid computed tomographic (CT) angiography. The perioperative stroke rate was 1.2%. When the old DUS velocity criteria for nonstented carotid arteries were applied, 54% of patients had > or = 30% restenosis (PSV of > 120 cm/s), but when our new proposed DUS velocity criteria for stented arteries were applied (PSV of > 155 cm/s), 33% had > or = 30% restenosis at a mean follow-up of 18 months (p = .007). The mean PSVs for patients with normal stented carotid arteries based on CT angiography, were 122 cm/s versus 243 cm/s for > or = 30% restenosis and 113 cm/s versus 230 cm/s for > or = 30% restenosis based on our new criteria. The mean PSVs of in-stent restenosis of 30 to < 50%, 50 to < 70%, and 70 to 99%, based on CT angiography, were 205 cm/s, 264 cm/s, and 435 cm/s, respectively. Receiver operating curve analysis demonstrated that an ICA PSV of > 155 cm/s was optimal for detecting > or = 30% in-stent restenosis, with a sensitivity of 100%, a specificity of 90%, a positive predictive value of 74%, and a negative predictive value of 100%. The currently used carotid DUS velocity criteria overestimated the incidence of in-stent restenosis. We propose new velocity criteria for the ICA PSV of > 155 cm/s to define > or = 30% in-stent restenosis.

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BACKGROUND/PURPOSE: Several studies have reported that carotid endarterectomy (CEA) with patch angioplasty produces superior results compared with primary closure. Conventional polytetrafluoroethylene (PTFE) patching has been shown to have results comparable to autogenous vein patching; however, it requires a prolonged hemostasis time. Therefore, many surgeons use collagen-impregnated Dacron patching (Hemashield [HP]). Recently, we reported a satisfactory hemostasis time using the new hemostatic PTFE patch (ACUSEAL by Gore). This study is the first prospective randomized trial comparing the ACUSEAL patch with the HP Finesse patch. METHODS: 200 CEAs were 1:1 randomized into two patch closure groups (ACUSEAL or Finesse). All patients underwent immediate and 1 month postoperative duplex ultrasound studies. Demographic and clinical characteristics were similar in both groups, including the mean operative diameter of the internal carotid artery and length of arteriotomy. RESULTS: The overall perioperative ipsilateral stroke rate was 2% (2% ACUSEAL, 2% Finesse; P = 1.0). The perioperative ipsilateral TIA rates were 0% for the ACUSEAL and 2% for the Finesse patch (P = .5). The combined perioperative neurological event (TIA + stroke) rates were 2% for ACUSEAL and 4% for the Finesse (P = .68). The early >or=50% restenosis rate was 0% for ACUSEAL vs 4% for Finesse patching. Two perioperative carotid thromboses were noted with Finesse patching vs none with ACUSEAL patching (P = .50). The combined early morbidity rate (TIA, stroke, and >or=50% restenosis or thrombosis) was 2% for the ACUSEAL patch vs 8% for the Finesse patch (P = .10). The mean hemostasis time for the ACUSEAL and Finesse patches was 5.1 vs 3.7 minutes (P = .01), however, the mean operative times were similar for both groups (P = .61). CONCLUSION: The perioperative neurological events and overall short-term morbidity associated with CEA when using ACUSEAL or Finesse patches were similar. Both patches have short hemostasis times.

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Injury remains the leading cause of childhood mortality for children younger than 14 years of age, with the liver being particularly susceptible to blunt trauma in children. This study reviews the authors' institutions' experience with pediatric liver injuries in an attempt to establish current patterns of injury, management and outcomes. A single-center, retrospective review was conducted of 105 consecutive pediatric patients who presented with a traumatic liver injury from January 1996 through February 2004. Average patient age was 13.1+/-4.9 years and 58 per cent were male. Perihospital mortality was 8.6 per cent, with 67 per cent of mortality being attributed to head injury. The majority of patients were managed nonoperatively (81%). Liver injury was most often grade II (35%) by CT scan. Liver injury grade did not affect survival, but did affect injury management, with grade I and grade IV liver injuries more likely to be managed surgically (P < 0.001). Grade I liver injuries were associated with concomitant spleen injuries, whereas grade IV injuries were associated with pancreatic injuries. Surgical management was associated with a higher injury severity score (P = 0.005), higher mortality (P = 0.01), and with other associated injuries as well. Children experiencing blunt abdominal trauma are at risk of significant morbidity and mortality; however, these risks stem more likely from associated injuries than injury to the liver proper. Clinicians should maintain a high index of suspicion for potentially catastrophic associated injuries to the pancreas with high-grade liver injury.

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We sought to identify the results achieved with lower extremity amputations performed by both community and university-based surgeons as well as from multiple disciplines (orthopedic/general/vascular surgeons) serving a predominantly nonurban population. A review of 411 consecutive patients undergoing 508 non-traumatic lower extremity amputations at Charleston Area Medical Center from January 1999 to December 2003 was conducted. Amputations were performed most frequently at the below knee level (50.9%). Perioperative mortality (30-day) for the cohort was 11%. Mortality increased with more proximal level of initial amputations: 1.6% for transmetatarsal, 3.6% for below knee, 17.6% for above knee and 100% of those requiring hip disarticulation. Stump failure requiring conversion to a more proximal level was seen in 34.5% of TMA's, 12% of BKA, 6% of AKA during the follow-up period. Twenty-one percent of patients required bilateral amputations by the end of the follow-up period. Non-wound related morbidity for all procedures (i.e. pneumonia, stroke, renal failure) was 29%. Rehabilitation documentation was available for 55% of the cohort, of whom only 27% (N=61) were fitted for, and ambulating with a prosthesis during the follow-up period. Survival at 6 months, 1 year and 2 years was 59%, 47% and 23% respectively. Patients requiring major lower extremity amputation represent the peak of high-risk patients undergoing vascular surgery. Significant perioperative morbidity and limited survival is seen in this cohort. Early vascular surgery referral may reduce more proximal amputations and improve functional outcome in a group with poor longevity and limited functional capacity with amputation at the transtibial level and proximal.

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PURPOSE: This study was conducted to assess the efficacy of antibiotic-loaded polymethylmethacrylate (PMMA) beads in the management of lower extremity extracavitary prosthetic arterial graft infection. METHODS: This was a retrospective review of 34 patients treated for vascular surgical site (VSS) infections involving 36 prosthetic lower extremity arterial bypasses using antibiotic-loaded PMMA beads and culture-specific parenteral antibiotics for 4 to 6 weeks. Sites of graft infection were explored, debrided, and cultured. As determined from the results of Gram's stains of VSS purulence, PMMA powder was polymerized with an antibiotic (vancomycin, daptomycin, or tobramycin/gentamicin, or a combination), molded into a chain of beads, and implanted adjacent to the infected graft after debridement and pulsed-spray antibacterial lavage. All wounds were closed primarily with planned exploration to verify sterilization before a graft preservation or in situ replacement procedure. Treatment outcomes, including wound sterilization, were analyzed based on tissue culture isolates, procedures for persistent infection, and freedom from graft infection. RESULTS: Cultures isolated 42 pathogens, (32 gram-positive, 9 gram-negative, 1 Candida albicans) with methicillin-resistant Staphylococcus aureus (MRSA) cultured from 16 (44%) of 36 surgical site infections. As determined from the initial operative Gram's stain or a prior culture result, vancomycin PMMA beads were implanted in 29 of 36 VSS infections at the first procedure; daptomycin (n = 4) or tobramycin (n = 3) beads were implanted in the rest. Repeat VSS exploration and culture results led to an average of 2.5 antibiotic bead replacements before definitive treatment. A sterile (no growth on tissue culture) VSS was achieved in 87% of cases before a graft preservation (n = 16) or in-situ replacement of an infected graft (n = 20) procedure. No patient deaths occurred. Early and late limb salvage was 100%. Infection recurred in 4 (11%) VSSs during a mean 23-month follow-up period, one within 3 months owing to unrecognized bowel injury associated with in situ replacement of an aortofemoral graft limb. CONCLUSION: Antibiotic-loaded PMMA beads may be a useful adjunct in the contemporary surgical management of VSS infection involving a prosthetic graft. Wound sterilization was achieved in most VSSs before graft preservation or an in-situ replacement procedure, including infections caused by MRSA, a pathogen isolated in half of the extracavitary prosthetic graft infections. This preliminary trial shows the potential benefit of this new technique, but further study is required to prove efficacy.

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PURPOSE: This study was conducted to evaluate the impact of duplex ultrasound surveillance on the patency of femorofemoral bypasses performed for symptomatic peripheral arterial occlusive disease (PAOD). METHODS: A retrospective review was conducted of 108 patients (78 men, 30 women) with a mean age of 62 +/- 10 years who underwent femorofemoral prosthetic (n = 100) or vein (n = 8) bypass grafting for symptomatic PAOD (claudication, 38%; rest pain, 41%; tissue loss, 11%; infection, 10%) during a 10-year period. Prior or concomitant inflow iliac artery stenting was performed in 26 patients (24%), and a redo femorofemoral bypass was performed in 19 patients (18%). Duplex ultrasound surveillance of the reconstruction was performed at 6-month intervals to assess patency, graft (midgraft peak systolic flow velocity) hemodynamics, and identify inflow or outflow stenotic lesions. Repair was recommended for a stenosis with a peak systolic velocity (PSV) >300 cm/s and a PSV ratio >3.5. Life-table analysis was used to estimate primary, assisted-primary, and secondary graft patency. RESULTS: During a mean 40-month follow-up (range, 2 to 120 months), 31 bypasses (29%) were revised: 19 duplex-detected stenosis involving the inflow iliac artery (n = 15) or anastomotic stenosis (n = 4), or both, 11 for graft thrombosis, and 1 for graft infection. Abnormal inflow iliac (PSV >300 cm/s) hemodynamics or a mid-graft PSV <60 cm/s was measured in eight of 11 grafts before thrombosis. Mean time to revision was 30 +/- 17 months. The primary graft patency at 1, 3, and 5 years was 86%, 78%, and 62%, respectively. Correction of duplex-detected stenosis resulted in assisted-primary patency of 95% at 1 year and 88% at 3 and 5 years (P < .0001, log-rank). Secondary graft patency was 98% at 1 year and 93% at 3 and 5 years. CONCLUSIONS: Vascular laboratory surveillance after femorofemoral bypass that included duplex ultrasound imaging of the inflow iliac artery and graft accurately identified failing grafts. A duplex-detected identified stenosis with a PSV >300 cm/s correlated with failure, and repair of identified lesions was associated with excellent 5-year patency.

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PURPOSE: Nearly 40% of all-terrain vehicle (ATV) crash-related fatalities involve pediatric patients, with many of these patients dying from head and neck injuries. West Virginia is in a unique position to examine these injuries because of its high rate of ATV use. This study examines craniofacial ATV-related trauma in children. PATIENTS AND METHODS: We conducted a single-center, retrospective, descriptive study of 26 children presenting with a craniofacial injury(ies) resulting from an ATV crash from January 2001 to December 2004. RESULTS: Twenty-six children (65% boys) with a mean age of 13.1 years presented with craniofacial injuries during the study period. Two patients were helmeted. Mortality was 3.8% (n = 1, head injury related, postinjury day 3). Patients were most often drivers of the ATV (65%), although girls were more likely to be passengers (P = .03). Facial contusions, lacerations, and abrasions were highly prevalent (62%, 69%, 65%, respectively), as were fractures of the facial bones and skull (77%). Thirty-five percent sustained closed head injuries, which were significantly associated with mandible fractures (odds ratio 12.8%; 95% CI, 1.15-143). Mean length of hospital stay was 4.6 +/- 5 days, and 36% required an ICU stay (mean, 5.1 +/- 3 days). Twenty-four percent required ventilator support (mean, 107 +/- 43 hours; range, 48 to 168 hours). Operative intervention was required in 72% of patients (n = 18). CONCLUSION: Maxillofacial injury patterns from ATV-related crashes in children suggest a high percentage of significant facial injuries and closed head injuries. As new ATV legislation that addresses operator use is enacted, a decrease in the number and severity of craniofacial injuries may be seen.

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OBJECTIVE: Ultrasound-guided thrombin injection has become the initial treatment of choice for femoral access-related pseudoaneurysms. Patients typically undergo serial duplex examinations to assess for spontaneous resolution of small iatrogenic pseudoaneurysms (IPSAs) (<2.5 cm), or may require repeated diagnostic, therapeutic, and follow-up studies for larger IPSAs (>2.5 cm). We evaluated the impact of a revised treatment algorithm that includes primary treatment of both small (<2.5 cm) and larger pseudoaneurysms (>2.5 cm), rather than observation of smaller ones, and attempts to establish a single duplex examination via a point-of-care treatment strategy. METHODS: We reviewed 105 consecutive patients treated with ultrasound-guided thrombin injection from July 2001 through September 2004. Patient, IPSAs, characteristics, and treatment methods were examined. The number of duplex examinations per patient was evaluated over the treatment interval. Also, published cost data were used to compare primary treatment of small ISPAs vs observation with serial duplex examinations. RESULTS: Successful thrombosis occurred in 103 (98.1%) of 105 treated pseudoaneurysms. No minor or major complications occurred after thrombin injection in either small or large ISPAs, and both failures requiring operation were in the large aneurysm group. The recurrence rate for the series was 1.9% (2/105), and both recurrences were successfully treated with an additional thrombin injection. A single injection was successful in treating 43 (97.7%) of 44 small (<2.5 cm) IPSAs, and one required a second injection. Patients had an average of 3.3 duplex examinations in our first year of treatment experience, which declined to 1.5 by our third year with the institution of a point-of-care service model for all pseudoaneurysms. Based on this decreased use of duplex examination and an average treatment cohort of 35 IPSA patients per year our institution, we determined this results in a reduction of 35 hours of laboratory time and nearly 70 ultrasounds per year. Similarly for small pseudoaneurysms, a point-of-service primary treatment program rather than observation results in an estimated cost savings of $12,000, based on treating 15 small IPSAs per year. CONCLUSIONS: Ultrasound-guided thrombin injection is safe and effective for the treatment of nearly all iatrogenic pseudoaneurysms. We recommend primary treatment of small pseudoaneurysms by ultrasound-guided thrombin injection rather than observation with serial duplex scans. A point-of-care treatment algorithm can result in cost savings by reducing the number of necessary duplex examinations.

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Iatrogenic pseudoaneurysms will continue to be a problem associated with arterial cannulation procedures. With the increasing trend toward minimally invasive procedures, vascular surgeons, as well as interventionalists will be performing more cannulation procedures; hence we will be more involved in the management of this complication more frequently. Treatment trends and efforts aimed at preventing iatrogenic pseudoaneurysms have evolved over the past decade. This article reviews the history and available literature on the subject, in conjunction with the experience of a center that performs over 10,000 cannulation procedures annually.

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Major lower extremity amputations continue to be associated with significant morbidity and mortality, yet few recent large series have evaluated factors associated with perioperative mortality and wound complications. The purpose of this study was to examine factors affecting perioperative mortality and wound-related complications following major lower extremity amputation. A retrospective review was conducted of all adult patients who underwent nontraumatic major lower extremity amputations over a 5-year period at a single tertiary-care center in southern West Virginia. Demographic and clinical data, perioperative data, and outcomes were collected and analyzed to identify any relationship with perioperative mortality, as well as wound complications and early revisions (within 90 days) to a more proximal level. Variables were examined using chi-squared, two-tailed t-tests, and logistic regression. Three hundred eighty patients (61% male) underwent 412 major lower extremity amputations during 1999-2003. The initial level of amputation included 230 below-knee (BKA), 149 above-knee (AKA), and one hip disarticulation. Perioperative mortality was 15.5% (n = 59). From a regression model, age, albumin level, AKA, and lack of a previous coronary artery bypass graft (CABG) were independently related to mortality. Patients who did not have a previous CABG were nearly three times more likely to die than those who did (p = 0.038). Overall early wound complications were noted in 13.4% (n = 51). Four factors were independently related to experiencing a 90-day wound complication: BKA, community (rather than care facility) living, type of anesthesia, and preoperative hematocrit >30%. Major lower extremity amputation in patients with peripheral vascular disease continues to be associated with considerable perioperative morbidity and mortality. Even though the surgical procedure itself may not be challenging from a technical standpoint, underlying medical conditions put this group at high risk for perioperative death. Wound-healing problems are frequently encountered and must be minimized to facilitate early mobilization and hospital discharge.

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Inferior vena cava filters provide an alternative method of protection against pulmonary embolism in situations where anticoagulation either fails or is contraindicated. These filters are easily placed, with a relatively minor risk of complications. Currently, we know of only one reported case of filter migration using the TrapEase filter. We present a case report of a migrating TrapEase filter, as well as pulmonary embolism after TrapEase filter placement. This complication developed in a 31-year-old trauma patient who developed bilateral popliteal deep vein thromboses and an initial pulmonary embolus while on low molecular weight heparin.

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Factors affecting survival and mortality rate of patients who present with ruptured abdominal aortic aneurysms (AAAs) at our community hospital were established in the late 1980s. During the intervening years, there have been many improvements in medical care. This study was conducted to re-examine factors affecting survival to ascertain whether improvements in care processes have led to corresponding improvements in survival. Outcomes of 73 patients who presented with ruptured AAA from 1983 to 1987 were previously reported. A retrospective chart review was conducted of 84 similar patients from 15 subsequent years. Demographic data, preoperative assessments, treatment timings, intraoperative findings, and subsequent postoperative complications were collected, analyzed, and compared to this institution's previous reported experience. Of 84 patients reviewed, 80% were male. The mean age was 72 years. Overall mortality significantly decreased from past experience (62% compared to 44%, p = 0.03). The mortality rate specifically associated with a free intraperitoneal rupture significantly decreased (97% to 63%, p < 0.001) from our previous report, while mortality for those with retroperitoneal rupture was relatively unchanged. Patients at increased risk in the present series were those aged >70 years and had preoperative hemoglobin of <10, preoperative hematocrit of <28, and an initial emergency department systolic blood pressure of <120 in contrast to patients aged >80 and with hemoglobin of <8 in the previously reported series. Syncope, delays in beginning surgical treatment, and amount of blood loss were not significantly associated with death as had been reported previously. Type of rupture and preoperative hemoglobin were the two factors most significantly associated with death (p < 0.05 by logistic regression). Despite the improvements in patient care and knowledge of the problem, many patients (44%) still die from ruptured AAAs, and 70% of this mortality occurs during the first 24 hr. Type of rupture continues to be an important predictor of mortality, and a large amount of improvement in mortality can be attributed to improvements in treating free intraperitoneal ruptures. Treating physicians have not gained much control over factors significantly affecting mortality, but a refinement of the known factors affecting survival may help target interventions and tailor patient care. Improved prerupture treatments of aneurysms by elective operations are still essential for reducing fatal outcomes.

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The persistent high incidence of limb loss resulting from advanced forefoot tissue loss and infection in diabetic patients prompted an evaluation of transmetatarsal (TMA) and transtarsal/midfoot amputations in achieving foot salvage at our tertiary vascular practice. Over the last 8 years, 74 diabetic patients required 77 TMAs for tissue loss and/or infection. Twelve (16%) of the patients had a contralateral below-knee amputation (BKA) and 26% (n = 20) had dialysis-dependent renal failure. Thirty-five (45%) limbs had concomitant revascularization (bypass grafting or percutaneous transluminal angioplasty), 32 (42%) had arterial occlusive disease by noninvasive testing and/or arteriography but were not or could not be revascularized, and seven (13%) had normal hemodynamics. Patient factors, arterial testing, operative complications, operative mortality (<60 days), wound healing (at 90 days), limb salvage, functional status, and survival were evaluated during a mean follow-up of 20 months (range 3-48). Operative mortality was 5% (n = 4) after TMA and/or midfoot amputation. Although 32 TMAs initially healed (44%), six BKAs were required 5-38 months later. Of the 41 nonhealing TMAs (56%), progressive infection/tissue loss necessitated major amputation of nine limbs. Chopart (n = 22) or Lisfranc (n = 10) midfoot amputations were done in the remaining 32 nonhealing TMAs. Despite additional wound revisions in 14 patients (44%), major amputation was needed in six limbs. However, functional ambulation was achieved in 23 of 25 (92%) limbs with healed midfoot amputations, and foot salvage was possible in 61% (25/41) of nonhealing TMAs. Overall limb salvage for TMA/midfoot procedures was estimated from Kaplain-Meier life tables to be 73%, 68%, and 62% at 1, 3, and 5 years, respectively, with only 50% of dialysis patients avoiding major amputation. Ankle pressure >100 mm Hg and a biphasic pedal waveform had a positive predictive value (PPV) of 79%, and toe pressure >50 mm Hg had a PPV of 91% for determining healing of TMA/midfoot amputations. One- and 3-year survival rates were only 72% and 69% for the entire cohort from life table estimates. Aggressive attempts at foot salvage are justified in diabetic patients with advanced forefoot tissue loss/infection after assuring adequate arterial perfusion. Transtarsal amputations salvaged over half of nonhealing TMAs with excellent functional results.

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