Management of Warfarin Anticoagulation in Patients with Fractured Neck of Femur

Background. Most orthopaedic units do not have a policy for reversal of anticoagulation in patients with hip fractures. The aim of this study was to examine the current practice in a district general hospital and determine difference in the time to surgery, if any, with cessation of warfarin versus cessation and treatment with vitamin K. Methods. A retrospective review of the case notes between January 2005 and December 2008 identified 1797 patients with fracture neck of femur. Fifty seven (3.2%) patients were on warfarin at the time of admission. Patients were divided into 2 groups (A and B). Group A patients (16/57; 28%) were treated with cessation of warfarin only and group B patients (41; 72%) received pharmacological therapy in addition to stopping warfarin. Time to surgery between the two groups was compared. Results. The mean INR on admission was 2.9 (range 1.7–6.5) and prior to surgery 1.4 (range 1.0–2.1). Thirty eight patients received vitamin K only and 3 patients received fresh frozen plasma and vitamin K. The average time to surgery was 4.4 days in group A and 2.4 days in group B. The difference was statistically significant (P < .01). Conclusion. Reversal of high INR is important to avoid significant delay in surgery. There is a need for a national policy for reversing warfarin anticoagulation in patients with hip fractures requiring surgery. Vitamin K is safe and effective for anticoagulation reversal in hip fracture patients

A Case Report of Coronary-Subclavian Steal Syndrome Treated with Carotid to Axillary Artery Bypass

Coronary-subclavian steal syndrome results from atherosclerotic disease of the proximal subclavian artery causing reversal of flow in an internal mammary artery used as conduit for coronary artery bypass. This rare complication of cardiac revascularisation leads to recurrence of myocardial ischaemia. When feasible, subclavian angioplasty and/or stent placement can provide acceptable result for these patients. Vascular reconstruction through carotid to subclavian artery bypass has been the standard procedure of choice. Other interventions in literature include axilloaxillary bypass and subclavian carotid transposition. This case report describes the use of carotid axillary artery bypass for the treatment of coronary-subclavian steal syndrome

Aortoesophageal Fistula after Endovascular Aortic Aneurysm Repair of a Mycotic Thoracic Aneurysm

Mycotic aneurysms constitute a small proportion of aortic aneurysms. Endovascular repair of mycotic aneurysms has been applied with good short-term and midterm results. However, the uncommon aortoenteric fistula formation remains a potentially fatal complication when repairing such infective aneurysms. We present the case of an 80-year-old woman with thoracic and abdominal aortic mycotic aneurysms, which were successfully treated with endografting. However, the patient presented 3 months later with upper gastrointestinal bleeding secondary to erosion of the thoracic graft into the oesophagus. The patient was treated conservatively due to the high risk of surgical repair. There is currently little exposure to the management of mycotic aortic aneurysms. If suspected, imaging of the entire vasculature will aid initial diagnosis and highlight the extent of the disease process, allowing for efficient management. Aortic endografting for mycotic thoracic aneurysms is a high-risk procedure yet is still an appropriate intervention. Aortoenteric fistulae pose a rare but severe complication of aortic endografting in this setting

The Mysterious Risk of Arterial Thrombosis With COVID-19:A Case Series and Systematic Review of Acute Limb Ischaemia

Introduction: Coronavirus disease 2019 (COVID-19) generates a cytokine storm that predisposes patients to systemic complications including arterial thrombosis (AT) and acute limb ischaemia (ALI). This study reviews our understanding of the incidence and outcomes of patients with COVID-19 who develop AT. Methods: The case notes of all emergency patients with COVID-19 referred to the vascular services between March 2020 and March 2021 were reviewed. The study was undertaken to measure 30-day outcomes. Additionally, a literature search was undertaken according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using the following search terms: acute limb ischaemia OR arterial thrombosis OR thrombectomy OR embolectomy AND COVID-19. Results: During March 2020 and March 2021, 60,000 people tested positive for COVID-19 in Norfolk. A total of 33 patients were referred to the vascular services, of which 15 had AT (estimated incidence of 0.03%). Of AT patients, 93% had ALL Fourteen locations of AT were identified. Of ATs, 36% were infrainguinal. The 30-day mortality was 60%. Three patients underwent surgery: two embolectomies (one requiring subsequent below-knee amputation (BKA) and the other died) and one primary BKA requiring subsequent above-knee amputation. The 30-day amputation-free survival (AFS) rate was 29%. The literature search identified 361 studies prior to a thorough full-text review. Nine case series were included with more than 10 participants each. The incidence of AT was reported as high as 15%. In-hospital mortality was 40%, with a significant proportion undergoing amputation or palliative care. Approximately a third of patients undergoing revascularisation subsequently re-occluded. AFS remained as low as 25%. Conclusion: The incidence of AT within the vascular surgery territory in COVID-19 patients is low; however, it is associated with poor 30-day AFS. A computed tomography angiography protocol including the entire major vessels may be indicated in COVID-19 patients

Predicting features of visceral stent failure in fenestrated endovascular aortic aneurysm repair

Purpose: Visceral stents in fenestrated endovascular aortic repair (FEVAR) have a significant risk of complications and carry a considerable burden of reinterventions. The aim of this study is to identify preoperative and intraoperative predictors of visceral stent failure. Materials: A retrospective review of 75 consecutive FEVARs in a single center from 2013 to 2021 was undertaken. Data on mortality, stent failure, and reintervention pertaining to 226 visceral stents were collected. Methods: Anatomical features including aortic neck angulation, aneurysm diameter, and angulation of target viscerals were obtained from preoperative computed tomography (CT) scans. Stent oversizing and intraprocedural complications were recorded. Postoperative CT scans were analyzed to determine the length of cover of target vessels. Results: Only bridging stents through fenestrations to visceral vessels were considered; 28 (37%) cases had 4 visceral stents, 24 (32%) had 3, 19 (25%) had 2, 4 (5%) had 1. Thirty day mortality was 8%, a third of which was related to visceral stent complications. Intraprocedural complexity was documented during the cannulation of 8 (3.5%) target vessels, with a technical success rate of 98.7%. A significant endoleak or visceral stent failure was identified in 22 stents (9.8%) postoperatively, of which 7 (3%) had in-patient reintervention within 30 days. Further reinterventions at 1, 2, and 3 years were 12 (5.4%), 2 (1%), and 1 (0.4%), respectively. Most reinterventions were for renal stents (n=19, 86%). A smaller stent diameter and a shorter length of visceral stent were significant predictors of failure. No other anatomical feature or stent choice was found to be a significant predictor of failure. Conclusions: The modality of visceral stent failures varies, but renal stents with a smaller diameter and/or shorter length are more likely to fail over time. Their complications and reinterventions are common and carry a significant burden; therefore, close surveillance must be continued long term. Clinical impact: With this work we share the methodology adopted at our centre to treat juxtarenal aneurysm with FEVAR. Thanks to this detailed review of anatomical and technical features we provide guidance for endovascular surgeons to face hostile aneurysm with peculiar visceral vessels anatomy. With our findings will also motivate industries in their attempt to produce improved technologies able to overcome issues identified in this paper

Successful medical management of emphysematous gastritis with concomitant portal venous air: a case report

<p>Abstract</p> <p>Introduction</p> <p>The causes of diffuse abdominal pain following pelvic surgery are numerous. We present a rare case of acute abdominal pain in a woman in the post-partum period.</p> <p>Case presentation</p> <p>A 25-year-old Caucasian woman with neurofibromatosis type 1 presented to our hospital with diffuse abdominal pain immediately after a cesarean section. The patient was acutely ill and toxic with a fever of 38.8°C, a pulse of 120 beats per minute and a distended abdomen with absent bowel sounds. A computed tomography scan showed air in the wall of the stomach and portal venous system. The patient was successfully treated with intravenous antibiotics, bowel rest and total parenteral nutrition.</p> <p>Conclusion</p> <p>It is rare for a case of emphysematous gastritis associated with portal venous air to be treated successfully without surgery. To the best of our knowledge, to date there has been no reported association of emphysematous gastritis with neurofibromatosis.</p

Cardiac tamponade secondary to haemopericardium in a patient on warfarin

Excessive anticoagulation with warfarin may contribute to certain complications, including bleeding into body cavities. Haemopericardiac tamponade secondary to warfarin is rare outside cardiac surgery. The present report describes an unusual presentation of spontaneous cardiac tamponade in a patient on warfarin and recently treated for chest infection with erythromycin. The patient was referred to the surgeons with acute abdominal pain and hypotension. Blood tests revealed an international normalised ratio (INR) of 16.9. An emergency abdominal computed tomography (CT) scan revealed pericardial effusion. Intravenous vitamin K and prothrombin complex concentrate were administered and urgent referral to a cardiologist was made for pericardiocentesis. Monitoring INR in patients on warfarin is paramount in avoiding the potential detrimental complications of excessive anticoagulation. Clinicians should be aware of drug interactions of warfarin and risk factors associated with its prolonged half-life. Internal bleeding, including haemorrhagic cardiac tamponade, should be ruled out in patients with unexplained hypotension and excessive anticoagulation

Mycotic aneurysms of the abdominal aorta due to Listeria monocytogenes

AbstractINTRODUCTIONInfected abdominal aortic aneurysms (AAAs) can present insidiously with non-specific symptoms or they may present as ruptured AAA in the classical manner.PRESENTATION OF CASEWe report two cases of mycotic AAA with Listeria monocytogenes. One patient presented with a ruptured aneurysm, while the other patient had a symptomatic non-ruptured presentation with computer tomography (CT) angiogram demonstrating peri-aortic inflammatory change of a rapidly expanding aneurysm. Both patients were treated with excision of the infected tissue and inlay prosthetic surgical repair as well as long term antibiotics.DISCUSSIONArterial aneurysms caused by L. monocytogenes are rare. Risk factors include immunosuppression, infective endocarditis, intravenous drug use and septicaemia. Listeria infections should be discussed with the Health Protection Agency and local microbiologists due to their ubiquity.CONCLUSIONAbdominal aortic aneurysm due to L. monocytogenes is best managed via surgical resection in combination with long term antimicrobial therapy. The role of endovascular exclusion is unclear