Cases reported "Wounds, Gunshot"

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1/20. Double layered autogenous vein graft patch reconstruction of the common carotid-internal jugular fistula caused by gunshot wound.

    Hereby we present a case with a common carotid-internal jugular fistula caused by gunshot wound. The patient was a 32-year old male who had an entrance hole of a bullet on his right anterior cervical area, at the C4 level with a hematoma surrounding it. The exit hole could be detected at the sublingual area. By palpation a thrill and on auscultation a souffle was noted. Neither crepitation, nor any neurologic deficit or any symptom of Horner's syndrome was present. The emergency digital subtraction angiography (DSA) showed a fistulisation to internal jugular vein (IJV) approximately 0.5 cm below the common carotid artery (CCA) bifurcation level. During the operation a hematoma and a false aneurysm was observed on the CCA. Also, proximally to the bifurcation, a communication of CCA with IJV was noted. The wall of the JJV was rather thinned and the size of the vessel had considerably enlarged. Following the evacuation of the hematoma and debridement, the integration of the artery was achieved by placing a double layered autogenous vein graft patch over the 0.5 x 1.5 cm defect. The 0.3 x 1.5 cm defect laterally over the IJV was primarily sutured. The patient was discharged on the fifth day. The control DSA taken on the twelfth day showed a perfect integration of the vessels. We considered the case noticeable due to its rather rare incidence and the double layered autogen vein patch graft reconstruction.
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2/20. Transesophageal echocardiographic identification of an abdominal aortic pseudoaneurysm complemented by a transpulmonary echo contrast agent.

    Pseudoaneurysm of the abdominal aorta, a rare complication after traumatic injuries, represents a diagnostic challenge for which sophisticated imaging modalities are often used for its early identification. We describe a case in which transesophageal echocardiographic examination complemented by a transpulmonary echo contrast agent was useful not only in demonstrating the pseudoaneurysm, but in helping to localize the intravascular communication between the aorta and the pseudoaneurysm.
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3/20. Carotid artery-sygmoid sinus fistula: a rare complication of gunshot wound on the base of the cranium.

    Vascular lesions without clinical manifestation may occur in cranial-facial wounds produced by bullets that course the base of the cranium. This work describes a rare kind of vascular complication in cranial-facial gunshot wound. The authors present the case of a patient, the victim of a cranium-maxillary gunshot wound. Carotid angiography revealed a carotid-sygmoid sinus fistula that filled the sygmoid and transverse sinuses, concomitant to the arterial angiographic phase. A direct communication between the external carotid artery and the sygmoid sinus was disclosed. We are not aware of any other description of this vascular complication in cranial gunshot wound. It is important to recognize this kind of complication in cases of cranial-facial gunshot wound, because new factors harmful to the brain perfusion systems are introduced, in addition to the alterations to venous return and intracranial pressure, caused by the primary trauma. The new non-invasive vascular diagnostic methods are proving useful in filling the gap left by arteriography, which is no longer used in these cases.
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4/20. Bullets and biliptysis.

    Biliptysis is a dramatic physical finding which suggests the presence of a direct communication (fistula) between the biliary and bronchial tree. We report a bronchial biliary fistula resulting from penetrating thoracoabdominal trauma and the use of positive-pressure ventilation to obtain initial fistula control prior to definitive surgical repair.
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5/20. popliteal artery pseudoaneurysm in a child due to gunshot injury.

    This is a case of a 12-year old boy who sustained gunshot injury to his left knee region. After initial debridement and closure of his wounds, the patient presented seven weeks later with a large pulsatile swelling of his lower thigh and painful flexion deformity of his knee. angiography revealed large pseudoaneurysm of the popliteal artery and arteriovenous communication. The patient underwent successful repair of his popliteal artery with autologous long saphenous vein graft. The initial diagnostic difficulty in these cases, the different types of injury and the therapeutic modalities of similar cases in the literature are discussed.
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6/20. The application of dermatotraction for primary skin closure.

    Management of an open wound is a problem frequently encountered in the treatment of fractures. skin grafting, rotational flaps, free flaps, and healing by secondary intention add a considerable amount of morbidity and cost to the patient. Therefore, it is ideal to obtain primary closure when possible. This communication describes a technique that uses spinal needles, using towel clips and the natural stretching ability of the skin to enable primary closure of wounds. The technique described uses dermatotraction to stretch the skin is a cost-effective way to achieve primary closure of large wounds with supplies that are readily available in every operating room.
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7/20. Endovascular stent graft treatment of a traumatic aortocaval fistula.

    Aortocaval fistula (ACF) is an infrequently reported sequela of trauma. Most ACF have been repaired via an open approach. During the past 10 years, there has been one reported case of spontaneous ACF and two cases of traumatic ACF repaired using an endovascular technique. We present a third case of traumatic ACF repaired with an endovascular stent graft. A 40-year-old male sustained two gunshot wounds to the right chest and one to the right upper abdomen. He was taken from the emergency department directly to the operating room, where an exploratory laparotomy was performed. Through-and-through injuries to the stomach and transverse colon were repaired primarily. Subsequently, the patient developed abdominal compartment syndrome. An urgent exploratory laparotomy was performed, revealing a nonbleeding hematoma on the posterior lateral surface of the right lobe of the liver, which was left undisturbed. Open abdominal management was instituted with vacuum pack closure. On the nineteenth hospital day, the patient again had a significant decrease in hematocrit. An aortogram was performed in order to evaluate the patient for intrahepatic arterial bleeding amenable to transcatheter embolization. There was no evidence of hepatic arterial bleeding. However, a supraceliac ACF was identified. The patient was taken to the operating room, and an AneuRx aortic extension cuff was advanced under fluoroscopy and deployed to cover the fistula. Completion angiography revealed total obliteration of the ACF and appropriate placement of the stent graft. Postoperatively, the patient was returned to the intensive care unit, where his hospital course was complicated by ventilator-associated pneumonia and sepsis. Repeat computed tomographic scanning 6 months and 1 year following this repair demonstrated patency of the graft without evidence of graft migration or aortocaval communication. Further research and experience are necessary with this technique regarding long-term outcome and technical aspects. In particular, the sizing problems associated with repair of acute traumatic ACF in emergency situations should be addressed. The endovascular approach provides an attractive and exciting alternative to traditional methods for repair of ACF.
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8/20. Traumatic fistula between internal iliac artery and external iliac vein.

    Traumatic iliac arteriovenous fistulas (AVFs) are extremely rare, with only two cases reported in literature involving the internal iliac artery and the external iliac vein. We report the case of a 23-year-old man who sustained a gunshot injury to the left lower quadrant of his abdomen and subsequently developed unilateral leg edema of "elephantiasic proportions." Intra-arterial digital subtraction angiography six years later was essential for diagnosis and comprehension of the pathomechanism. The angiographic examination showed an internal iliac false aneurysm, as well as a high-flow arteriovenous communication between the left internal iliac artery and external iliac vein complicated by thrombotic occlusion of the left common iliac vein. The initial vascular injury and the surgical management of simple ligation were thought to be responsible for the iliac AVF and the subsequent thrombosis of the common iliac vein. On the one hand, the thrombotic occlusion of proximal vein led to a sharp increase of mean pressure in the proximal and distal arteries and in the distal vein, resulting in chronic venous insufficiency with incompetent varicose veins. On the other hand, the restriction of venous outflow produced extreme peripheral edema and large superficial veins serving as collaterals to bypass the fistula. Vascular surgery could repair the lesion by closing and bypassing the AVF.
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9/20. Peripheral vascular gunshot bullet embolus migration to the cerebral circulation. Report and literature review.

    Bullet embolization to intracranial branches of the major cerebral arteries is a rare complication of gunshot wounds. A review of the literature on cerebral vascular bullet embolization from peripheral sources revealed a number of single case reports that included 12 cases involving the anterior cerebral circulation, and one which involved the posterior circulation. This communication details two additional subjects who were treated at our institution.
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10/20. carotid-cavernous sinus fistula complicating a complex shotgun facial injury.

    carotid-cavernous sinus fistula is a rare but major complication of severe head injuries. This pathological communication between the internal carotid artery and the surrounding cavernous sinus at the base of the skull may result in marked retinopathy, optic atrophy with permanent loss of vision, and, rarely, fatal epistaxis. Physical signs of this entity are pathognomonic and include marked chemosis, pulsating exophthalmos, and a pulse-synchronous supraorbital bruit. diagnosis is confirmed by carotid angiography or computed tomography scan. Treatment modalities range from internal carotid ligation to catheter embolectomy and, at times, observation. A patient with carotid-cavernous sinus fistula following complex facial trauma is described. The differential diagnosis and management of this rare pathological entity is discussed. In their position as primary consultants of head and neck trauma, plastic and reconstructive surgeons should be aware of both the diagnosis and management of this unusual condition.
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