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Iatrogenic Vascular Injuries
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
2013 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Iatrogenic vascular injuries (IVIs) and injuries associated with vascular surgery can cause severe morbidity and death. The aims of this thesis were to study those injuries in the Swedish vascular registry (Swedvasc), the Swedish medical injury insurance where insurance claims are registered, the Population and Cause of death registries, and in patient records, in order to explore preventive strategies.

Among 87 IVIs during varicose vein surgery 43 were venous, mostly causing bleeding in the groin. Among 44 arterial injuries, only 1/3 were detected intraoperatively. Accidental arterial stripping predominated, with poor outcome. Four patients died, all after venous injuries.

IVIs increased over time, and constitute more than half of the vascular injuries registered in the Swedvasc. Lethal outcome was more common (4.9%) among patients suffering IVIs than among non-iatrogenic vascular injuries (2.5%). Risk factors for death were age, diabetes, renal insufficiency and obstructive lung-disease.

Fifty-two patients died within 30 days after IVI. The most common lethal IVIs were puncture during endovascular procedures (n=24, 46%), penetrating trauma during open surgery (11) and occlusion after compression (6). Symptoms were peripheral ischemia (n=19), external bleeding (14), and hypovolemic chock without external bleeding (10). Most died within two weeks (n=36, 69%). After >2 weeks the IVI as a cause of death was uncertain.

Among 193 insurance claims after vascular surgery during 2002-2007, nerve injuries (91) and wound infections (22) dominated. Most patients suffered permanent injuries, three died. Patients with insurance claims were correctly registered in the Swedvasc in 82%.

In 32 cases of popliteal artery injury during knee arthroplasty symptoms were bleeding (n=14), ischaemia (n=7) and false aneurysm formation (n=11). Only twelve injuries (38%) were detected intraoperatively. Patency at 30 days was 97%, but only seven (22%) patients had complete recovery. Six of those had intraoperative diagnosis of popliteal injury and immediate vascular repair.

In conclusion, registration of IVIs is increasing and outcome is often negatively affected by diagnostic and therapeutic delay. Not all fatalities after IVIs are attributable to the injury itself. The most common causes of insurance claims after vascular surgery were nerve injuries, and 82% were correctly registered in Swedvasc.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2013. , 63 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 867
Keyword [en]
vascular injuries, vascular surgery, vascular trauma, injury, medical error, patient safety, postoperative death, postoperative mortality, patient insurance, varicose veins
National Category
Surgery
Research subject
Surgery
Identifiers
URN: urn:nbn:se:uu:diva-194346ISBN: 978-91-554-8597-9 (print)OAI: oai:DiVA.org:uu-194346DiVA: diva2:605251
Public defence
2013-04-12, Auditorium Minus, Museum Gustavianum, Akademigatan 3, Uppsala, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2013-03-22 Created: 2013-02-12 Last updated: 2013-04-02Bibliographically approved
List of papers
1. Iatrogenic vascular injuries in varicose vein surgery: a systematic review
Open this publication in new window or tab >>Iatrogenic vascular injuries in varicose vein surgery: a systematic review
2007 (English)In: World Journal of Surgery, ISSN 0364-2313, E-ISSN 1432-2323, Vol. 31, no 1, 228-233 p.Article, review/survey (Refereed) Published
Abstract [en]

Iatrogenic vascular injuries during varicose vein surgery are serious. The aim of this study was to investigate their nature and consequences.A systematic literature research was performed.The incidence is low (0.0017%-0.3%). We found 81 patients suffering from 87 vascular injuries—44 arterial and 43 deep vein injuries.Vascular injuries during varicose surgery are rare but serious. They are avoidable, and when they occur, early recognition is crucial. Bleeding is a common symptom, especially in deep venous injury. In our study, we reviewed the literature on 81 patients with 87 vascular injuries. Laceration or division of the femoral vein dominated venous injuries (28/43). Partial stripping of the femoral vein was not common (4/43) and occurred when the strip probe passed into the deep veins through a perforator. Arterial stripping predominated in arterial injuries (17/44) and happened when stripping distally during a primary operation, as reported by experienced surgeons, in nonobese women. Major arterial complications resulted in ischemia, often with diagnostic delay and poor reconstruction results. Only 30% (13/44) of arterial injuries were detected peroperatively. The amputation rate was 34% (15/44), but rose to 100% if combined with intra-arterial sclerotherapy (5/5 cases). When stripping an artery below the femoral artery, the amputation rate was high (42%; 5/12) and morbidity severe (85%; 11/12). All fatal injuries (5 cases) were venous. Anatomic knowledge and awareness of the possibility of vascular complications should be preventive. Early detection by routine checking of arterial circulation is important.

Keyword
Femoral Artery/*injuries, Femoral Vein/*injuries, Humans, Iatrogenic Disease/*epidemiology, Lacerations/*epidemiology, Varicose Veins/*surgery, Vascular Surgical Procedures/*adverse effects
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-10977 (URN)10.1007/s00268-006-0492-8 (DOI)000243365100038 ()17180475 (PubMedID)
Available from: 2007-05-08 Created: 2007-05-08 Last updated: 2017-12-11Bibliographically approved
2. Iatrogenic vascular injuries in Sweden. A nationwide study 1987-2005
Open this publication in new window or tab >>Iatrogenic vascular injuries in Sweden. A nationwide study 1987-2005
2008 (English)In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 35, no 2, 131-138 p.Article in journal (Refereed) Published
Abstract [en]

Objectives. To study the epidemiology of vascular injuries, with special focus on Iatrogenic Vascular Injuries (IVIs) and time-trends.

Design and methods. From the Swedish national vascular registry, Swedvasc, prospectively registered data on vascular injuries during 1987-2005 were analysed and cross-referenced for mortality against the population registry.

Results. Of 1853 injuries, 48% were caused by iatrogenic, 29% penetrating and 23% blunt trauma. In the three groups median age was 68, 35 and 40 years, respectively. The annual incidence of procedures for vascular injuries increased from 1.2-1.6 per 100 000 inhabitants and the proportion of IVIs increased from 41 to 51%, during the period. Mortality was higher after IVI (4.9%) compared to non-IVI (2.5%). Patients with IVI also had more co-morbidities; 58% cardiac disease, 44% hypertension, and 18% renal dysfunction.

Among 888 IVIs, right femoral arterial injury was the most frequent (37%). The most common vascular reconstruction was direct suture (39%) followed by by-pass or interposition graft (19%, of which prosthetics were used in over half the cases). Endovascular repair increased from 4.6% to 15% between 1987 and 2005.

Conclusions. Vascular injuries, in particular iatrogenic ones, appear to be increasing. Iatrogenic injuries affect vulnerable patients with co-morbidities and are associated with a high mortality.

Keyword
iatrogenic, vascular injury, arterial injury, vascular trauma
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-16609 (URN)10.1016/j.ejvs.2007.09.010 (DOI)000253380400002 ()17996467 (PubMedID)
Available from: 2008-05-29 Created: 2008-05-29 Last updated: 2017-12-08Bibliographically approved
3. Insurance Claims after Vascular Surgery in Sweden
Open this publication in new window or tab >>Insurance Claims after Vascular Surgery in Sweden
2011 (English)In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 42, no 4, 495-505 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVES:

The study aimed to estimate the incidence and causes of insurance claims (IC) after vascular surgery (VS) reported to the Swedish Medical Injury Insurance (SMII); and to validate the registration of complications in the National Vascular Registry (Swedvasc).

METHODS:

The medical records of all IC in VS in Sweden reported to the SMII 2002-2007 were scrutinised and cross-referenced against Swedvasc.

RESULTS:

There were 193 claims after VS: varicose-veins (66), lower extremity (45), aortic (31) or carotid artery (21), access (19) or other VS (11). Frequent causes of claims were peripheral nerve injury (76), wound infection (22) and cranial nerve injury (15). More than half of the patients suffered permanent injuries, three died. As many as 55 (28%) received economic compensation (an average of 45% of all ICs in SMII). The highest frequency of compensated claims (1:650 yearly procedures) was for carotid artery surgery. Of the procedures, 187 were elective. Compared with the Swedvasc, claudication was a more common indication (28% vs. 12%). Nearly one-fifth (18%) were incorrectly registered in Swedvasc.

CONCLUSIONS:

The most common causes of insurance claims were peripheral nerve injuries and infections. Patients raising insurance claims after vascular surgery undergo acute procedures less frequently, and are correctly registered in the Swedvasc in 82% of cases.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-157170 (URN)10.1016/j.ejvs.2011.04.026 (DOI)000296042600019 ()21669541 (PubMedID)
Available from: 2011-08-18 Created: 2011-08-18 Last updated: 2017-12-08Bibliographically approved
4. Iatrogenic vascular injuries with lethal outcome
Open this publication in new window or tab >>Iatrogenic vascular injuries with lethal outcome
2013 (English)In: World Journal of Surgery, ISSN 0364-2313, E-ISSN 1432-2323, Vol. 37, no 8, 1981-1987 p.Article in journal (Refereed) Published
Abstract [en]

Objectives

The aim was to study the nature of iatrogenic vascular injuries (IVIs) associated with postoperative death within 30 days. Patients who had undergone vascular surgery for IVIs and were reported prospectively to the Swedish national vascular registry during 1987-2008 were identified. They were cross-checked with the national population registry. Those who died within 30 days of surgery were studied regarding case records and death certificates. A total of 56 patients with postoperative death within 30 days after IVI were identified. Among them, 52 case records were retrieved (93 %). In 24 cases the IVIs were caused by puncture during endovascular procedures (13 hemorrhage, 11 occlusive thrombosis), 11 by penetrating trauma during open surgery, 6 by occlusion after external compression, 6 by percutaneous accidental arterial puncture. Main symptoms were peripheral ischemia (19/52, 37 %), external bleeding (14, 27 %), and hypovolemic shock without external bleeding (10, 19 %). Main specialties involved were interventional radiology (n = 18), general surgery (n = 9), and interventional cardiology (n = 8). Overall, 22 (42 %) were avoidable, and only 13 (25 %) underwent autopsy. Within 2 weeks, 36 patients (69 %) were dead. Also, there was a higher proportion with uncertain correlation between IVI and death. Interventional radiology, general surgery, and cardiology are the main specialities involved in IVIs with lethal outcome. Not all fatalities after IVI are attributable to the injury itself, but almost half of the injuries were considered avoidable.

Methods

Patients who had undergone vascular surgery for IVIs, and were reported prospectively to the Swedish national vascular registry 1987–2008 were identified. They were cross-checked with the national population registry and those who died within 30 days of surgery were studied regarding case-records and death certificates.

Results

Fifty-seven patients with postoperative death within 3o days after IVI were identified and of those 53 case records were retrieved (93%). In 24 cases the IVIs were caused by puncture during endovascular procedures (13 hemorrhages, 11 occlusive thrombosis), eleven by penetrating traumas during open surgery, six were occlusions after external compression, six were percutaneous accidental arterial punctures. Main symptoms were peripheral ischemia (n=19/53, 36%), external bleeding (n=14, 26%), hypovolemic chock without external bleeding (n=10, 19%). Main specialties involved were interventional radiology (n=20), general surgery (n=9) and interventional cardiology (n=8). Twenty-two (41%) were avoidable, only 13 (25%) underwent autopsy. Within two weeks 34 (70%) were dead. After two weeks there was a higher proportion with uncertain correlation between IVI and death.

Conclusion

Interventional radiology and general surgery and cardiology are the main specialities involved in IVIs with lethal outcome. All fatalities after IVIs are not attributable to the injury itself, but almost half of the injuries were considered avoidable.

Keyword
Iatrogenic injury, vascular surgery, postoperative mortality, lethal injuries, medical errors
National Category
Surgery
Research subject
Surgery
Identifiers
urn:nbn:se:uu:diva-194349 (URN)10.1007/s00268-013-2061-2 (DOI)000322023600033 ()23640723 (PubMedID)
Available from: 2013-02-12 Created: 2013-02-12 Last updated: 2017-12-06Bibliographically approved
5. Popliteal artery injury in knee arthroplasty: a population based, nationwide study
Open this publication in new window or tab >>Popliteal artery injury in knee arthroplasty: a population based, nationwide study
2013 (English)In: Journal of Bone and Joint Surgery, ISSN 0301-620X, E-ISSN 2044-5377, Vol. 95, no 12, 1645-1649 p.Article in journal (Other academic) Published
Abstract [en]

Popliteal artery injury (PAI) is a feared but rare complication during knee arthroplasty (KA). The aim was to study PAI during KA: Type of injury, treatment and outcome.

Thirty-two cases were identified in the national Swedish vascular registry (Swedvasc) and the Swedish Patient Insurance databases. Prospective data from the registries was supplemented with case-records, including long-term follow-up.

Twenty-five injuries (78%) were due to penetrating, seven to blunt trauma. Three different presentations of injury were identified: Bleeding (n=14), ischaemia (n=7) and false aneurysm formation (n=11). Five (16%) cases were during revision KA. Twelve injuries (38%) were detected intraoperatively, eight (25%) within 24 hours (range 3-24) and twelve (38%) >24 hours postoperatively (range 2-90), 28 (88%) were treated with open surgery. Patency at 30 days was 97% (one amputation). Twenty-five (78%) patients had residual symptoms at the end of follow-up (median 546 days, range: 24-1251). Six of the seven patients with complete recovery had an early diagnosis of the PAI during the procedure, and were treated by a vascular surgeon in the same hospital.

Outcome after popliteal artery injury during KA is often negatively affected by diagnostic and therapeutic delay. Bleeding and pseudoaneurysm were the most common clinical presentations.

Keyword
Vascular injury, popliteal artery, knee arthroplasty, complication, adverse event, pseudoaneurysm
National Category
Orthopedics Surgery
Research subject
Surgery
Identifiers
urn:nbn:se:uu:diva-194380 (URN)10.1302/0301-620X.95B12.31611 (DOI)000327788000010 ()24293594 (PubMedID)
Funder
Swedish Research Council, K2010-65X-20406-04-3
Available from: 2013-02-13 Created: 2013-02-13 Last updated: 2017-12-06Bibliographically approved

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