David Kauvar

All Publications

• Outcomes Associated With Aortic Balloon Occlusion Time in Patients With Zone 1 Resuscitative Endovascular Balloon Occlusion of the Aorta JOURNAL OF SURGICAL RESEARCH Treffalls, R. N., DuBose, J. J., Brenner, M., Piccinini, A., Inaba, K., Scalea, T. M., Moore, L. J., Kauvar, D. S., Aortic Occlusion Resuscitation 2024; 296: 256-264

  Abstract

  Resuscitative endovascular balloon occlusion of the aorta (REBOA) has the potential to cause clinically relevant systemic ischemic burden with long durations of aortic occlusion (AO). We aimed to examine the association between balloon occlusion time and clinical complications and mortality outcomes in patients undergoing zone 1 REBOA.A retrospective cohort analysis of American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acuteregistry patients with Zone 1 REBOA between 2013 and 2022 was performed. Patients with cardiopulmonary resuscitation on arrival or who did not survive past the emergency department were excluded. Total AO times were categorized as follows: <15 min, 15-30 min, 31-60 min, and >60 min. Clinical and procedural variables and in-hospital outcomes were compared across groups using bivariate and multivariate regression analyses.There were 327 cases meeting inclusion criteria (n = 51 < 15 min, 83 15-30 min, 98 31-60 min, and 95 > 60 min, respectively). AO >60 min had higher admission lactate (8 ± 6; P = 0.004) compared to all other time groups, but injury severity score, heart rate, and systolic blood pressure were similar. Group average times from admission to definitive hemorrhage control ranged from 82 to 103 min and were similar across groups (85 min in AO >60 group). Longer AO times were associated with greater red blood cell, fresh frozen plasma transfusions (P < 0.001), and vasopressor use (P = 0.001). Mortality was greatest in the >60 min group (73%) versus the <15 min, 15-30 min, and 31-60 min groups (53%, 43%, and 45%, P < 0.001). With adjustment for injury severity score, systolic blood pressure, and lactate, AO >60 min had greater mortality (OR 3.7, 95% CI 1.6-9.4; P < 0.001) than other AO duration groups. Among 153 survivors, AO >60 min had a higher rate of multiple organ failure (15.4%) compared to the other AO durations (0%, 0%, and 4%, P = 0.02). There were no differences in amputation rates (0.7%) or spinal cord ischemia (1.4%). acute kidney injury was seen in 41% of >60 min versus 21%, 27%, and 33%, P = 0.42.Though greater preocclusion physiologic injury may have been present, REBOA-induced ischemic insult was correlated with poor patient outcomes, specifically, REBOA inflation time >60 min had higher rates of mortality and multiple organ failure. Minimizing AO duration should be prioritized, and AO should not delay achieving definitive hemostasis. Partial REBOA may be a solution to extend safe AO time and deserves further study.

  View details for DOI 10.1016/j.jss.2023.12.044

  View details for Web of Science ID 001175360200001

  View details for PubMedID 38295713

• Acute Aortic Syndromes from Diagnosis to Treatment-A Comprehensive Review JOURNAL OF CLINICAL MEDICINE Banceu, C. M., Banceu, D. M., Kauvar, D. S., Popentiu, A., Voth, V., Liebrich, M., Neamtu, M., Oprean, M., Cristutiu, D., Harpa, M., Brinzaniuc, K., Suciu, H. 2024; 13 (5)

  View details for DOI 10.3390/jcm13051231

  View details for Web of Science ID 001182707200001

• Acute Aortic Syndromes from Diagnosis to Treatment-A Comprehensive Review. Journal of clinical medicine Banceu, C. M., Banceu, D. M., Kauvar, D. S., Popentiu, A., Voth, V., Liebrich, M., Halic Neamtu, M., Oprean, M., Cristutiu, D., Harpa, M., Brinzaniuc, K., Suciu, H. 2024; 13 (5)

  Abstract

  This work aims to provide a comprehensive description of the characteristics of a group of acute aortic diseases that are all potentially life-threatening and are collectively referred to as acute aortic syndromes (AASs). There have been recent developments in the care and diagnostic plan for AAS. A substantial clinical index of suspicion is required to identify AASs before irreversible fatal consequences arise because of their indefinite symptoms and physical indicators. A methodical approach to the diagnosis of AAS is addressed. Timely and suitable therapy should be started immediately after diagnosis. Improving clinical outcomes requires centralising patients with AAS in high-volume centres with high-volume surgeons. Consequently, the management of these patients benefits from the increased use of aortic centres, multidisciplinary teams and an "aorta code". Each acute aortic entity requires a different patient treatment strategy; these are outlined below. Finally, numerous preventive strategies for AAS are discussed. The keys to good results are early diagnosis, understanding the natural history of these disorders and, where necessary, prompt surgical intervention. It is important to keep in mind that chest pain does not necessarily correspond with coronary heart disease and to be alert to the possible existence of aortic diseases because once antiplatelet drugs are administered, a blocked coagulation system can complicate aortic surgery and affect prognosis. The management of AAS in "aortic centres" improves long-term outcomes and decreases mortality rates.

  View details for DOI 10.3390/jcm13051231

  View details for PubMedID 38592069

• Vascular Reconstruction and Limb Loss in Military Tibial Artery Injuries. Annals of vascular surgery Lee, C. S., Scheidt, J., Causey, M. W., Kauvar, D. S. 2023

  Abstract

  Selective operative management of injuries to the tibial arteries is controversial, with the necessity of revascularization in the face of multiple tibial arteries debated. Tibial artery injuries are frequently encountered in military trauma, but revascularization practices and outcomes are poorly defined. We aimed to investigate associations between the number of injured vessels and reconstruction and limb loss rates in military casualties with tibial arterial trauma METHODS: A US military database of lower extremity vascular injuries from Iraq and Afghanistan (2004-2012) was queried for limbs sustaining at least one tibial artery injury. Injury, intervention characteristics, and limb outcomes were analyzed by the number of tibial arteries injured (one, T1; two, T2; three, T3).221 limbs were included (194 T1, 22 T2, 5 T3). The proportions with concomitant venous, orthopaedic, nerve, or proximal arterial injuries were similar between groups. Arterial reconstruction (versus ligation) was performed in 29% of T1, 63% of T2, and universally in T3 limbs (P<0.001, Figure). Arterial reconstruction was via vein graft (versus localized repair) in 62% of T1, 54% of T2, and 80% of T3 (P=0.59). T3 received greater blood transfusion volume (P=0.02), and fasciotomy was used universally (versus 34% T1 and 14% T2, P=0.05). Amputation rates were 23% for T1, 26% for T2, and 60% for T3 (p=0.16), and amputation was not significantly predicted by arterial ligation in T1 (P=0.08) or T2 (P=0.34) limbs. Limb infection was more common in T3 (80%) than in T1 (25%) or T2 (32%, p=0.02), but other limb complication rates were similar.In this series of military lower extremity injuries, an increasing number of tibial arteries injured was associated with the increasing use of arterial reconstruction. Limbs with all three tibial arteries injured had high rates of complex vascular reconstruction and eventual amputation. Limb loss was not predicted by arterial ligation in one- and two-vessel injuries, suggesting that selective reconstruction in these cases is advisable.

  View details for DOI 10.1016/j.avsg.2023.09.099

  View details for PubMedID 37926142

• Association Between Time to Revascularization and Limb Loss in Military Femoropopliteal Arterial Injuries. Journal of vascular surgery Vuoncino, M., Scheidt, J., Kauvar, D. S. 2023

  Abstract

  BACKGROUND: Expeditious revascularization is key to limb salvage after arterial injuries, but the relationship between time to revascularization and amputation risk is not well-defined. We aimed to explore amputation risk based on time to revascularization in a cohort of military femoropopliteal arterial injuries.METHODS: A database of vascular injuries from Iraq and Afghanistan casualties (2004-2012) was queried for femoral (common, superficial, or deep) and/or popliteal arterial injuries that underwent revascularization. Time from injury to initial revascularization (via shunt or reconstruction) was divided into groups of < 3h, 3-6h, 6-9h, and > 9h and bivariate comparisons were performed.RESULTS: Revascularization times were available for 120 cases. Injury and treatment characteristics by time group were generally similar between time groups. Shunting and vein injuries were more common in limbs revascularized earlier, while blast mechanism and fasciotomy were more common with later revascularization. Ten (8%) cases underwent revascularization in less than 3 hours, 63 (53%) were revascularized in 3-6 hours, 33 (28%) in 6-9 hours, and 14 (12%) after 9 hours. Amputation rates within the cohorts were 10%, 21%, 24%, and 50%, respectively (P=0.085, Figure 1). (P=0.085, chi square of amputation rates across time groups). The mean ± SD revascularization time for amputated limbs was 442 ± 348 min vs 347 ± 183 min for salvaged limbs (P=0.057). Amputation was performed in 19% of limbs revascularized in < 6h and in 32% revascularized > 6h from injury (P=0.112). The > 9h group, however, had a 50% amputation rate vs 21% for those with revascularization in <9h. (P=0.016). Fractures were more common in > 9h limbs than < 9h (79% vs 44%, P=0.016), but other limb injury characteristics were similar, with no difference in limb injury severity scores. Among 91 salvaged limbs, neither vascular nor other complications were predicted by time to revascularization. All seven > 9h limbs had a limb complication, most commonly infection (71%), and three (42%) required a skin graft to close their fasciotomies.CONCLUSIONS: Increasing time from injury to initial revascularization was associated with increasing rates of limb loss. Revascularization within 3 hours of injury resulted in a low amputation rate, while half of limbs treated after 9 hours were amputated. Arterial shunting was associated with earlier revascularization and should be considered a mainstay of combat casualty vascular care. Forward deployed surgical assets play a pivotal role in providing early revascularization and reducing rates of limb loss in modern combat casualty care.

  View details for DOI 10.1016/j.jvs.2023.07.055

  View details for PubMedID 37541556