Radial neuropathy following arterial line removal: A rare complication from a routine ICU procedure

Radial artery thrombosis is a rare complication of cannulation. There are no reported cases of acute thrombosis and severe acute neuropathy in the setting of cannula discontinuation. We report a case of acute radial nerve mono-neuropathy following thrombosis after radial arterial line removal. The thrombus was immediately evident on exam and diagnostic imaging after cannula discontinuation. The patient was consented and promptly taken to OR for immediate repair. Mild radial neuropathy persisted despite immediate repair. Immediate recognition of signs and symptoms is essential for diagnosis and management, especially in the high-risk population

Laser Fenestration for Treatment of a Complicated Chronic Type B Aortic Dissection.

We report a case of a complex chronic type B aortic dissection treated by thoracic endovascular aortic repair and laser fenestration of the false septum to preserve flow to branch vessels originating from both the true and false lumen. Dissections complicated by thoracoabdominal aneurysmal degeneration with critical organs being perfused by branches arising from both true and false lumens are rare and leave limited options for repair. Despite advancements in endovascular techniques, fenestration remains one of the only means of preserving flow to both the true and false lumens and thus was necessary in the management of our patient. This novel procedure allows complex aortic dissections to be addressed endovascularly, which increases the flexibility and management of this challenging problem that previously required an open repair with significant morbidity

Surgical Scarring after Arterial Bypass, an Etiology of Venous Hypertension.

Venous ulcers can be a chronic debilitating condition with a high rate of recurrence. Herein, we describe a case of a patient who successfully underwent an arterial bypass for rest pain but returned with lower extremity swelling and venous ulcers. Venography demonstrated a focal common femoral vein stenosis due to scarring from the surgical exposure. This was treated with endovenous stenting and resulted in resolution of the swelling and ulceration

Direct aortic access for endovascular thoracoabdominal aneurysm repair using a bifurcated endograft as a branched device

Aortic aneurysms (AA) are a common complication in patients with large-vessel vasculitis, such as chronic phase Takayasu arteritis, that often require surgical management to prevent a lethal rupture. Historically, mainstay of treatment for AA in the setting of arteritis was traditional open repair. However, in this case study an alternative surgical approach was devised to successfully treat an extent III thoracoabdominal AA in a patient with a diagnosis of Takayasu arteritis and a complex surgical history that made her high risk for an open surgical intervention. This case study summarizes a hybrid surgical approach that successfully excluded a thoracoabdominal AA and revascularized the superior mesenteric artery and left renal artery, by directly accessing the infrarenal aorta and using a bifurcated abdominal aortic endograft as a two-vessel branched device

Iliofemoral deep venous thrombosis in kidney transplant patients can cause graft dysfunction

We present a series of kidney transplant dysfunction secondary to lower extremity deep venous thrombosis (DVT). A 70-year-old man underwent living unrelated kidney transplantation and presented 2 months postoperatively with acute kidney injury (AKI) secondary to external iliac vein thrombosis. Graft function improved after endovascular intervention. A 43-year-old man underwent living unrelated kidney transplantation and presented 3 years postoperatively with AKI secondary to external iliac vein thrombosis. Graft function recovered after thrombolysis. A 42-year-old woman underwent simultaneous pancreas and kidney transplantation. Four weeks postoperatively, she had AKI secondary to common femoral vein DVT. Her graft function improved after common iliac vein stenting. A 67-year-old man underwent living unrelated kidney transplantation and presented a week later with lower extremity DVT and AKI. His graft function improved with anticoagulation. Iliofemoral DVT can cause allograft dysfunction. The cause may be multifactorial. Endovascular intervention is safe and feasible when anticoagulation fails. Keywords: Renal transplant, Iliofemoral deep vein thrombosis, Graft dysfunctio

Lower extremity ischemia, an ominous complication after elective EVAR

Objectives: Elective endovascular repair (EVAR) is considered to be a safe and effective intervention for abdominal aortic dissection. Although rare, ischemic complications after EVAR are highly feared. In particular, data on lower extremity ischemia (LEI) after EVAR are sparse. Our objective was to determine the impact of LEI on outcomes after elective EVAR in a national database. Methods: We queried the American College of Surgeons National Safety Quality Improvement Project participant and corresponding procedure targeted data files for EVAR from 2011 to 2015 to identify and compare clinical features, operative details, and 30-day outcomes of elective EVAR. Patients with incomplete data sets with regards to evaluated factors were excluded from analysis. Bivariate and multivariate analyses were performed using SAS software (SAS Institute, Inc, Cary, SC). Results: Of 8981 patients who underwent elective EVAR, 137 patients (1.52%) developed LEI. The Table shows that patients who developed LEI were significantly more likely to also develop pneumonia (3.3% vs 0.5%; P = .014), renal failure requiring dialysis (4.4 vs 0.4%; P \u3c .001), skin and soft tissue infection (4.4 vs 1.2; P = .024), deep venous thrombosis (4.4% vs 0.2%; P \u3c .0001), and required return to the operating room (80% vs 2.74%; P \u3c .0001). Inpatient mortality was also significantly higher in this group (6.7 vs 0.5%; P \u3c .0001; Table). On multivariate regression controlling for patient characteristics, perioperative characteristics and postoperative complications known to be associated with LEI, odds of inpatient mortality remained higher among patients with LEI than those without (odds ratio, 7.032; 91% confidence interval, 2.362-20.939; Table). Additionally, LEI was associated with higher odds of an extended hospital length of stay, defined as length of stay \u3e75 percentile (odds ratio, 1.652; 95% confidence interval, 1.029-2.652; Table). Other significant predictors of inpatient mortality in these elective EVAR patients include operative time and postoperative renal failure requiring dialysis, whereas male sex was associated with lower odds of inpatient mortality. Conclusions: LEI after elective EVAR increases the risk of inpatient mortality after EVAR by almost tenfold. As such, careful intraoperative assessment of the access site and bilateral lower extremity circulation is critical for early recognition and management of this morbid and often deadly postoperative complication

Ultrasound-assisted catheter directed thrombolysis for pulmonary embolus during extracorporeal membrane oxygenation

Background: Acute pulmonary embolism (PE) is the third most common cause of cardiovascular death. For patients who are hemodynamically unstable, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support has been shown to provide hemodynamic stability, and allow time for definitive treatment and recovery. Ultrasound-assisted catheter directed thrombolysis (USAT) has the potential to be a safe adjunct and expedite right ventricular (RV) recovery for patients requiring VA-ECMO for PE. Methods: A review of all VA-ECMO patients from January 2017 to September 2019 was performed. A total of 49 of these patients were cannulated due to a PE. USAT therapy was used as an adjunct in 6 (12%) of these patients. These 6 patients were given standardized USAT therapy with EKOs catheters at 1 mg/h of tissue plasminogen activator with an unfractionated heparin infusion for additional systemic anticoagulation. Outcomes, including in-hospital death, 90-day survival, RV recovery, and complications, were examined in the cohort of patients that received USAT as an adjunct to ECMO. Results: Median age was 54 years old. Five of the six patients presented with a massive PE and had a PE severity score of Class V. One patient presented with a submassive PE with a Bova score of 2, but was cannulated to VA-ECMO in the setting of worsening RV function. All patients demonstrated recovery of RV function, were free from in-hospital death, and were alive at 90-day follow-up. Conclusion: Ekosonic endovascular system therapy may be a safe and feasible adjunct for patients on VA-ECMO for PE, and allow for survival with RV recovery with minimal complications