Vascular injury during laparoscopic cholecystectomy:An oftenoverlooked complication

Laparoscopic cholecystectomy is one of the most frequently performed procedures in gastrointestinal surgery worldwide.Bleeding complications due to vascular injuries represent an important cause of morbidity and mortality,especially when facing major bleeding during laparoscopy,where bleeding control can be technically challenging in inexperienced hands.Interestingly,the reported incidence rate of conversion to open surgery due to vascular lesions is approximately 0%-1.9%,with a mortality rate of approximately 0.02%.The primary aim of this article was to perform an up-to-date overview regarding the incidence and surgical management of vascular injuries during laparoscopic cholecystectomy according to the available scientific evidence.

Feasibility study of emergency intervention for vascular injury outside the hospital

Background: Minimally invasive surgery in the field of traumatic vascular injury diagnosis and treatment has achieved good results. This study was designed to determine whether pre-hospital emergency intervention is feasible for vascular injury in a field intervention cabin under the condition of war or a disaster site.Methods: Different types of animal experiments of vascular injury intervention were performed in a field intervention cabin. Treatment capacity was evaluated by data collection, including duration of surgery, clinical evaluation, image clarity, and equipment handling. Environmental adaptability and mobility were evaluated by maneuverability and long-distance mobility.Results: A total of 56 surgeries(7 types) were performed in the field intervention cabin. Digital subtraction angiography(DSA) had good imaging performance. A total of 4800 km of long-distance mobility was performed, and all the equipment operated normally without any equipment failure. We participated in the medical service maneuver twice. The cabin unfolded and worked properly. There was no equipment damage during the medical service maneuver.Conclusion: Use of a field intervention cabin under the conditions of war or disaster is feasible for pre-hospital emergency intervention of vascular injury.

Management of major vascular injury in laparoscopic urology

Objective:During the past three decades,laparoscopy has played a significant role in the management of urological disorders.This study aims to standardize the management of major vascular injury,which is a life-threatening complication in the laparoscopic urological procedures.Methods:A total of 8210 patients with the urological disorder,who underwent laparoscopic surgery at Sir Run Run Shaw Hospital from January 2000 to December 2018,were included in this retrospective study.Patients’data of the laparoscopic major vascular injury were collected and analyzed,and the basic principles of the procedure were summarized.Results:A total of 15(0.18%)cases of major vascular injury were found among the 8210 patients,and 2 of them were converted to open surgery.Although the type of laparoscopic surgery,causes,and management of major vascular injury among the patients were diverse,the main management strategies of major vascular injury in laparoscopic surgery were to keep the vision clear,control bleeding rapidly by clamping and compression,make full preparation for possibly needed liquid resuscitation,and try best to repair under laparoscope.If necessary,converse to open surgery.Conclusion:Although the reported incidence of major vascular injury in laparoscopic urological surgery is extremely low,such injury can result in high morbidity and mortality.It is important to rapidly identify the cause and strictly follow the standardized management for better outcomes.

The Pattern and Outcome of Civilian Vascular Injury in a Teaching Hospital over a 7-Year Period

Background: The exact incidence of vascular injuries in Nigeria as a country especially south-east zone of Nigeria is unknown on account of under reporting and uncoordinated management of victims. Aim: To determine the pattern and outcome of common civilian vascular injuries managed in a teaching hospital in the south-east zone of Nigeria. Method: This is a retrospective study from January, 2007 to December, 2013. All case records of common civilian vascular injuries presenting at the accident center and those referred to the clinics as well as operation register and data banks of managing surgeons, were retrieved and analysed. Results: The age range of 12 - 75 years was rec-orded for the 26 patients. In this spectrum, age range of 21 - 30 years (19.2%) was the highest while the age range, 61 - 70 years (0%) was the lowest. One female (3.9%) and twenty five males (96.1%) were recorded, giving a female to male ratio of 1:25. In the upper extremity, brachial artery 6 (23.1%) was the most involved vessel while in the lower extremity, the most involved was the femoral artery 9 (34.6%). The patterns of presentation were isolated bleeding 10 (38%), arterivenous fistula 1 (3.5%) and pseudoaneurysm 8 (30%). 23 (88%) had good outcome. Conclusion: The incidence is about 4 cases per year. 23 (88%) had good outcome. The shortcoming of lattending physicians was because they were not conversant with hard and soft signs of vascular injuries with attendant limb loss and death of one of the victims. This short coming can be averted by training and retraining of doctors.

Upper extremity vascular injuries:Etiology,management and outcome

BACKGROUND Vascular injuries of the upper extremities are considered relatively rare injuries affecting mostly the young population.They often are complex injuries accompanied by other musculoskeletal trauma or trauma in other anatomic locations.Their management is challenging since they can lead to disabilities with major socioeconomic effects.AIM To analyze data about the mechanism of injury,the management algorithm and functional outcomes of vascular injuries of the upper extremity.METHODS One hundred and fifteen patients(96 males and 19 females)with arterial injuries of the upper extremity treated in a tertiary trauma center from January 2003 to December 2022 was conducted.Mean patients’age was 33.7 years and the mean follow up time was 7.4 years.Patients with Mangled Extremity Severity Score≥7 and Injury Severity Score≥20,previous upper limb surgery or major trauma and any neuromuscular or psychiatric disease were excluded,from the study.RESULTS A penetrating trauma was the most common cause of injury.The radial artery was the artery injured in most of the cases(37.4%)followed by the ulnar(29.5%),the brachial(12.1%)and the axillary(6%).A simultaneous injury of both of the forearm’s arteries was in 15.6%of the cases.In 93%of the cases there were other concomitant musculoskeletal injuries of the extremity.Tendon lacerations were the most common,followed by nerve injuries.The postoperative functional scores(full Disabilities of the Arm,Shoulder,and Hand and VAS)had very satisfactory values.CONCLUSION Although vascular injuries of the upper extremity are rare,they may occur in the context of major combined musculoskeletal trauma.Although a multidisciplinary approach is essential to optimize outcome,the ability of trained hand surgeons to repair all injuries in combined vascular and musculoskeletal upper extremity trauma,excluding isolated vascular injuries,ensures shorter operative times and better functional outcomes.

Continuous positive airway pressure for treating hypoxemia due to pulmonary vein injury:A case report

BACKGROUND Vascular injury during thoracoscopic surgery for esophageal cancer is a rare but life-threatening complication that can lead to severe hypotension and hypoxemia.Anesthesiologists need to provide rapid and effective treatment to save patients'lives.CASE SUMMARY A 54-year-old male patient was scheduled to undergo a thoracoscopic-assisted radical resection of esophageal cancer through the upper abdomen and right chest.While dissociating the esophagus from the carina through the right chest,unexpected profuse bleeding occurred from a suspected pulmonary vascular hemorrhage.While the surgeon attempted to achieve hemostasis,the patient developed severe hypoxemia.The anesthesiologist implemented continuous positive airway pressure(CPAP)using a bronchial blocker(BB),which effectively improved the patient’s oxygenation and the operation was completed success-fully.CONCLUSION CPAP using a BB can resolve severe hypoxemia caused by accidental injury of the left inferior pulmonary vein during surgery.

External counterpulsation attenuates hypertensive vascular injury through enhancing the function of endothelial progenitor cells

Background Vascular injury is a landmark of hypertension and external counterpulsation（ECP） has been identified as a non-invasive treatment to restore the capacity of endothelial cells. However, the effect of ECP on blood pressure lowering in hypertension and the potential mechanism remain unknown. Methods We measured the ambulatory blood pressure（AMBP）and flow-mediated endothelial dilation（FMD） in the essential hypertensive patients who were randomly assigned to ECP group（n = 20） or control group（n = 20）. We also evaluated in vitro migration and adhesion function of endothelial progenitor cells（EPCs）. Furthermore, multivariate analysis was performed to determine the actual correlation between EPC function and FMD. Results Compared with the control, ECP group exhibited decreased systolic [（133.2 ± 4.9） mm Hg vs.（139.3 ± 6.4） mm Hg, P 〈0.05] and diastolic [（83.4 ± 4.5） mm Hg vs.（89.5 ± 7.6） mm Hg, P 〈 0.05] blood pressure and increased FMD value[（8.87 ± 2.46） % vs.（7.51 ± 2.32）%, P 〈 0.01]. In addition, the migration [（47.3 ± 6.4）/hpf vs.（33.4 ± 5.1） hpf,P 〈 0.05] and adhesion [（45.1 ± 5.5）/hpf vs.（28.4 ± 3.9） hpf, P 〈 0.05] function of EPCs in ECP group were improved significantly, while no change was observed in the control. Both migration（OR = 0.47, 95% CI： 0.27-0.64, P 〈 0.05） and adhesion（OR = 0.44, 95% CI：-0.0034-0.0012, P 〈 0.05） of EPCs correlated with FMD. After multivariate analysis, the migration（β = 3.37, 95% CI： 1.67-5.33, P 〈 0.05） and adhesion（β = 3.98, 95% CI：1.12-6.43, P 〈 0.05） function still independently correlated to FMD. Conclusions The present study demonstrates for the first time that ECP decreases both systolic and diastolic blood pressure and increases FMD value in hypertension. The fall in endogenous EPCs repair capacity might be an important mechanism of hypertensive vascular injury and could be restored by ECP.

Delayed Management of Popliteal Artery Injury Following Knee Dislocation—A Case Report

Knee dislocations frequently involve vascular injuries that demand early diagnosis and timely intervention. Time of ischemia is pivotal in determining the outcome for the limb, delays in treatment beyond 8 hours significantly increase the risk of limb loss. Unfortunately, this critical window is often missed in resource-limited settings. Here we report a 25-year-old female sustained a left knee injury after falling into a trench. She was diagnosed with an open knee dislocation accompanied by a popliteal artery injury. However, revascularization was delayed for 18 hours due to limited resources, including the unavailability of a thrombectomy catheter. Postoperatively, the patient received anticoagulation therapy with serial limb assessments and after 3 weeks the laceration healed and the limb was still viable. Knee dislocations frequently result in vascular injury (popliteal artery most common), making prompt diagnosis and intervention essential for limb preservation. In settings with limited resources, like ours, delayed presentation and transfer to specialized centers contribute to prolonged ischemic times. Nonetheless, viable limbs should be revascularized in stable patients, even with prolonged ischemia. This case highlights the importance of limb revascularization despite delay. Efforts should be made to improve prompt diagnosis, timely referral, and availability of necessary equipment for vascular repair to optimize outcomes in similar cases.

Patient survival and limb salvage after shark attack with major vascular injury:A case report

Shark attacks are rare unique pathological processes.Some of them represent devastating injuries with a high morbidity and significant mortality.Related published articles are limited.The increased human interaction within the environment of sharks is the cause of rising incidence of such attacks.This study reported a case of level 4 shark injuries(shark-induced trauma scale)in a 33-year-old male patient,who presented with an extensive injury of the right lower limb with the characteristic features of shark bite.At admission the patient was in a state of shock with profuse bleeding that was controlled by tourniquet.The patient was resuscitated according to the advanced trauma life support.Clinical examination showed hard signs of vascular injury with absent pedal pulse,associated neurological deficits and severance at the knee joint.Prompt vascular intervention after resuscitation was performed to manage the major vascular injuries,together with proper washout and debridement of all the necrotic tissues under strong antibiotic coverage to prevent infection.After that,the patient underwent sequenced plastic,orthopedic,and neurological interventions.Strict follow-up was conducted,which showed that the patient was saved and achieved a functioning limb.This study aims to highlight the management of level 4 shark injuries,which are considered serious and challenging with a high fatality rate and a great risk of amputation due to the associated major vascular injuries.Immediate well organized management plan is crucial.Prompt resuscitation and surgical intervention by a highly-skilled medical team are required to improve the chance of patient survival and limb salvage.

Efficacy and safety of Xuebijing injection in the treatment of vascular endothelial injury in sepsis patients:A meta-analysis

Objective:To systematically evaluate the efficacy and safety of Xuebijing injection in the treatment of vascular endothelial injury in sepsis,and to provide evidence-based reference for clinical medication.Methods:The randomized controlled trials of Xuebijing injection combined with conventional treatment(experimental group)versus conventional treatment(control group)for sepsis were collected by computer search of Chinese CNKI database,WANFANG database,and VIP database.Literature screening was performed according to the inclusion and exclusion criteria.According to the Cochrane International Collaboration Evaluator Workbook procedure,the quality evaluation and bias analysis were performed for the literatures included in the meta-analysis.Revman 5.3 software was used for systematic meta-analysis.Results:A total of 15 clinical randomized controlled trials with a total of 930 patients were included.Meta-analysis showed that Xuebijing injection combined with conventional therapy could reduce 28-day mortality in sepsis[OR=0.52,95%CI(0.38,0.71),P<0.0001],APACHEⅡintegral[WMD=-2.65,95%CI(-3.23,-2.08),P<0.00001];be effective in decreasing D-dimer[WMD=-0.79,95%CI(-1.17,-0.40),P<0.0001],TNF-α[WMD=-36.71,95%CI(-43.04,-30.39),P<0.00001],vWF[WMD=-15.94,95%CI(-27.60,-4.28),P=0.007],sE-selectin[WMD=-118.30,95%CI(-139.65,-96.95),P<0.00001],ESM-1[WMD=-135.44,95%CI(-186.30,-84.57),P<0.00001],sTM[WMD=-56.46,95%CI(-66.39,-46.53),P<0.00001];can effectively increase platelets[WMD=30.78,95%CI(25.65,35.92),P<0.00001].Conclusion:Xuebijing injection can not only effectively reduce the release of inflammatory factors,thereby improving vascular endothelial injury,reducing coagulation disorders and blocking coagulation-inflammation network;it can also increase the level of platelets,thereby repairing injured vascular endothelial cells,which has a certain value to reduce the condition of sepsis and improve the prognosis.It also provides some basis for the treatment of sepsis secondary to novel coronavirus pneumonia.

Carbon Monoxide Releasing Molecule Accelerates Reendothelialization after Carotid Artery Balloon Injury in Rat

Objective This study was aimed to investigate the effects of carbon monoxide releasing molecule （CORM-2）, a novel carbon monoxide carrier, on the reendothelialization of carotid artery in rat endothelial denudation model. Methods Male rats subjected to carotid artery balloon injury were treated with CORM-2, inactive CORM-2 （iCORM-2） or dimethyl sulfoxide （DMSO）. The reendothelialization capacity was evaluated by Evans Blue dye and the immunostaining with anti-CD31 antibody. The number of circulating endothelial progenitor cells （EPCs） was detected by flow cytometry. The proliferation, migration, and adhesion of human umbilical vein endothelial cells （HUVECs） were assessed by using [3H]thymidine, Boyden chamber and human fibronectin respectively. The expressions of protein were detected by using western blot analysis. Results CORM-2 remarkably accelerated the re-endothelialization 5 d later and inhibited neointima formation 28 d later. In addition, the number of peripheral EPCs significantly increased in CORM-2-treated rats than that in iCORM-2 or DMSO-treated rats after 5 d later. In vitro experiments, CORM-2 significantly enhanced the proliferation, migration and adhesion of HUVECs. The levels of Akt, eNOS phosphorylation, and NO generation in HUVECs were also much higher in CORM-2 treated group. Blocking of PI3K/Akt/eNOS signaling pathway markedly suppressed the enhanced migration and adhesion of HUVECs induced by CORM-2. Conclusion CORM-2 could promote endothelial repair, and inhibit neointima formation after carotid artery balloon injury, which might be associated with the function changes of HUVECs regulated by PI3K/Akt/eNOS pathway.

Flip-over of blood vessel intima caused by vascular closure device:A case report

BACKGROUND Complications of vascular closure devices mainly include bleeding,vascular injury,and trapped device that cannot be removed percutaneously.However,arterial stenosis or occlusion induced by vascular injury is rare.This article introduces a rare case with severe acute limb ischemia after using the vascular closure device(StarClose).CASE SUMMARY A 54-year-old man was admitted because of necrosis of the second toe of the left foot for 2 mo.Ultrasound showed left femoral artery stenosis,and occlusion of the left popliteal,posterior tibial,peroneal,anterior tibial and dorsalis pedis arteries,suggesting arteriosclerosis obliterans of low extremities,gangrene and type 2 diabetes.He underwent an interventional procedure of drug-eluting balloon in the left lower limb via antegrade puncture of the left common femoral artery.He developed acute limb ischemia after 1 h,and severe pain,numbness,pale skin,low skin temperature and weakened sensation in the left foot.Injury of the common femoral artery intima was considered.Exploratory surgery showed occlusion at the puncture point accompanied with bulged vascular lumen and flipped vascular intima caused by StarClose.The flipped intima was removed.The limb blood supply was restored and the limb was saved post-surgery.He recovered well at final follow-up.CONCLUSION Incorrect use of the vascular closure device was the main cause of severe acute limb ischemia in this case.

Update in combined musculoskeletal and vascular injuries of the extremities

Combined musculoskeletal and vascular injuries of the extremities are conditions in which a multidisciplinary approach is a sine qua non to ensure life initially and limb viability secondarily.Vascular injuries as part of musculoskeletal trauma are usually the result of the release of a high energy load in the wound site so that the prognosis is determined by the degree of soft-tissue damage,duration of limb ischemia,patient’s medical status and presence of associated injuries.The management of these injuries is challenging and requires a specific algorithm of action,because they are usually characterized by increased morbidity,amputation rate,infection,neurological and functional deficits,and they could be life threatening.Although vascular injuries are rare and occur either isolated or in the context of major combined musculoskeletal trauma,the high index of suspicion,imaging control,and timely referral of the patient to organized trauma centers ensure the best functional outcome of the extremity in such challenging cases.Even after a successful initial treatment of a combined trauma pattern,long-term follow-up is crucial to prevent and detect early possible complications.The purpose of this manuscript is to provide an update on diagnosis and treatment of combined musculoskeletal and vascular injuries of the extremities,from an orthopedic point of view.

Buyanghuanwu decoction promotes angiogenesis after cerebral ischemia/reperfusion injury：mechanisms of brain tissue repair

Buyanghuanwu decoction has been shown to protect against cerebral ischemia/reperfusion injury,but the underlying mechanisms remain unclear.In this study,rats were intragastrically given Buyanghuanwu decoction,15 m L/kg,for 3 days.A rat model of cerebral ischemia/reperfusion injury was established by middle cerebral artery occlusion.In rats administered Buyanghuanwu decoction,infarct volume was reduced,serum vascular endothelial growth factor and integrin αvβ3 levels were increased,and brain tissue vascular endothelial growth factor and CD34 expression levels were increased compared with untreated animals.These effects of Buyanghuanwu decoction were partially suppressed by an angiogenesis inhibitor（administered through the lateral ventricle for 7 consecutive days）.These data suggest that Buyanghuanwu decoction promotes angiogenesis,improves cerebral circulation,and enhances brain tissue repair after cerebral ischemia/reperfusion injury.

Magnetic resonance imaging and cell-based neurorestorative therapy after brain injury

Restorative cell-based therapies for experimental brain injury, such as stroke and traumatic brain injury,substantially improve functional outcome. We discuss and review state of the art magnetic resonance imaging methodologies and their applications related to cell-based treatment after brain injury. We focus on the potential of magnetic resonance imaging technique and its associated challenges to obtain useful new information related to cell migration, distribution, and quantitation, as well as vascular and neuronal remodeling in response to cell-based therapy after brain injury. The noninvasive nature of imaging might more readily help with translation of cell-based therapy from the laboratory to the clinic.

Effect of Aloe Emodin on Proliferation of Vascular Smooth Muscle Cells after Arterial Injury

Objective: To study the effect of Aloe emodin (AE), an active ingredient of Rhubarb,on the kinetics of proliferation of smooth muscular cells (SMCs) cultured in vitro after rabbit iliac arterial injury. Methods: Forty-eight hours after de-endothelialization (balloon endothelial denudation), the iliac arteries of the Japanese white rabbits were isolated and the smooth muscle cells were cultured primarily.AE was added to culture medium containing 10% fetal calf serum (FCS ). The cultures were pulse-labeled with 3H-TdR and TdR uptake into VSMC were measured and the cell cycle of the cultures were analyzed by using flow cytometer. Results: Compared with control, when the concentration gradient ranged from 10 - 1 to 10-5 g/L, the amount (cpm,count per minute) of 3H-TdR uptake into SMCs has significant differences (P < 0. 05 )and 10 -1 and 10 -2 g/L AE showed strong inhibitory effects on TdR uptake into VSMC and the percentage of inhibition [% inhibition =(cpm without AE-cpm with AE)/cpm without AE] was more than 90%. AE displayed concentration dependent inhibitory effects. The percentage of cells in G0/G1 phase was increased, but the percentage of cells in S phase was decreased in AE group, the transition of SMC cycle phase from G0 to S was blocked.Conclusion: AE is a strong inhibitor to the proliferation of SMCs and the pharmacological action of AE may reduce SMC proliferation in vivo and decrease intimal hyperplasia of restenosis.Original article on CJIM(Chin) 1998; 18(7): 420

Preventive effect of Fangshuan capsule on PCI-induced myocardial damage and vascular endothelial injury in patients with unstable angina pectoris

Objective To observe the prevention of Fangshuan Capsule(FC)on percutaneous coronary intervention(PCI)induced myocardial damage and vascular endothelial injury in patients with unstable angina pectoris(UAP).Methods Totally 100 UAP patients undergoing PCI were assigned to the control group and the

Varied presentations, magnitude, and outcome of traumatic neck injuries at a level I trauma center

Introduction:Traumatic neck injuries(TNIs)constitute 5%–10%of all trauma cases.These injuries can be caused by either penetrating or blunt trauma.Patients can have a varied presentation like cut injury over the neck,bleeding,neck swelling,breathing difficulty,dysphagia,etc.Methods:This was a retrospective observational study conducted at a level I trauma center in India from January 2016 to March 2020.One hundred thirty patients who required admission and intervention due to TNIs were included in this study.Results:One hundred thirty patients with neck injuries were included in this study.Males were predominant(91.5%)with the age ranging from 10 to 70years.The most common mechanism of injury was physical assault(40.7%),followed by road traffic injury(23.8%)and self-inflicted injuries(18.4%).Penetrating trauma was predominant.Open neck wound with bleeding was the most common presenting symptom.Zone II injuries were more common(83.8%)followed by zone I(12.3%)and zone III(3.8%).Soft tissue injury including skin,platysma breach,and strap muscle injury was present in 46.9% of patients.Laryngopharyngeal injury was present in 13.8%,tracheal injury in 28.5%,vascular injury in 13.8%,and esophageal injury in 4.6% of patients.Conclusion:Penetrating neck trauma is more common than blunt in developing countries like India.Advanced Trauma Life Support(ATLS)protocol guides the initial management.The definitive management depends on the type and mechanism of injury,anatomical level,severity,and the organ injured.

Effect of valsartan on Lectin-like oxidized-low density lipoprotein receptor-1 expression in balloon-injured rat aorta

Background It＇s established that Lectin-like involved in intimal hyperplasia after balloon injury oxidized low-density lipoprotein receptor-l（LOX-1） is The recent evidence also suggests that valsartan has an antiatheroscletic effect. In this study, the expression of LOX-1 and the effect of valsartan on its expression was investigated in rat aorta after balloon injury. Methods Rat model of aortic endothelial denudation was induced by 2F balloon catheter. Rats were randomly divided into three groups： control, operationand valsartan treatment. The aortic tissues were taken from rats in each group on days 14 and 28 after surgery. The thickness of vascular wall was measured with HE stain, LOX-1 mRNA and protein were determined by reverse transcription-polymerse chain reaction （RT-PCR） and immunohistochemistry, respectively. Results Compared with the control group, significant intimal thickening was observed at day 14 and 28 after injury. Compared with the operation group, intimal thickness of each time point was significantly decreased in valsartan treatment group. At day 14 and 28 after balloon injury, the expression levels of LOX-1 mRNA and protein were significantly increased, and were greatly decreased after valsartan treatment. Conclusions The expression of LOX-1 is increased after endothelial injury. Valsartan inhibits aortic intimal thickening induced by endothelial denudation, which is associated with the downregulation of LOX-1 expression.