Vascular complications occurring after diagnostic cardiac catheterization and percutaneous coronary interventions. incidence and management

This study was conducted on 48 patients [32 males and 16 females] with access site complications requiring vascular surgical consultation to evaluate the incidence and surgical management of arterial injuries resulting from diagnostic cardiac catheterization and percutaneous coronary interventions. The total number of patients underwent cardiac catheterization and percutaneous coronary interventions [PCI] were 822. The work was done at the Chest Hospital in the state of Kuwait during a 2-year period from December 1, 2004 to November 30, 2006. Thirty nine patients [81.2%] were ischaemic heart disease, thirty five [72.9%] were hypertensive, thirty [62.5%] were smokers, eleven [22.9%] were diabetics, twenty two [45.8%] were hyperlipidaemic and nineteen [39.5%] had a previous myocardial infarction. The reported complications were:- femoral artery pseudo aneurysm in 24 patients [50%], acute arterial thrombosis in 9 patients [18.7%], haematoma at the groin in 7 patients [14.5%], retroperitoneal haematoma in 2 patients [4.1%], intraperitoneal haemorrhage in one patient [2%], bleeding from the catheter puncture site in 3 patients [6.2%] and arteriovenous fistula [A/V fistula] in two patients [4.1%]. All patients were carefully evaluated by history taking and physical examination in addition to urgent routine laboratory investigations. Duplex study was performed in thirty one patients [64.5%], twenty four patients [50%] with femoral artery pseudo aneurysm and seven patients [14.5%] with groin haematoma. Abdominal ultrasound was carried out in three patients [6.2%], in two of them a massive retroperitoneal haematoma was documented while in the 3[rd] patient an intraperitoneal haemorrhage was detected. Blood transfusion needed urgently in 8 patients [16.6%] for patient's resuscitation before surgery due to massive blood loss. Of total 48 complications following diagnostic cardiac catheterization and PCI: fourteen patients [29.1%] underwent successful ultrasound guided pseudo aneurysm compression and 34 patients required surgical interventions. These surgical interventions were performed under local anaesthesia in 31 patients [91.1%], and under general anaesthesia in 3 patients [8.8%]. Of ten patients [20.8%] with femoral artery pseudo aneurysm [not responding to ultrasound guided compression], 7 patients [14.5%] of them underwent primary arterial repair, in the remaining three patients [6.2%] saphenous vein patches were used. Groin haematomas were evacuated in 7 patients [14.5%]. In 3 patients [6.2%] with severe catheter site bleeding primary repair was performed. In 9 patients [18.7%] with acute lower limb ischaemia, successful thrombectomy was performed in 5 patients [10.4%]. In 2 patients [4.1%] thrombectomy was performed and the arteriotomy closed with saphenous vein patches. While in the remaining 2 patients femoro-popliteal synthetic bypass graft was performed. In 2 patients [4.1%] with A/V fistulas direct repair of femoral artery and vein were performed. In 3 patients [6.2%] with massive retroperitoneal haematoma and intraperitoneal haemorrhage, ileo-femoral bypass grafting was performed due to exsanguinating arterial perforation and extensive intimal dissections. All patients were followed up at 1-, 3, 5-, 9- and 12 months after surgery as regard to the lower limb vascularity and graft patency which was determined by Doppler study. During the period of follow up no mortality occurred. But wound infection was documented in two patients [4.1%] after evacuation of groin haematoma. Diagnostic cardiac catheterization and PCI are associated with a low but significant risk of access site complications which is higher during PCI than with diagnostic procedures. Early recognition and management is very important to minimize the risk of these complications

Outcome of carotid endarterectomy in cases of symptomatic severe carotid artery stenosis

This study was conducted on 23 patients with symptomatic severe carotid artery stenosis [70-99%] to know the outcome and evaluate the results and efficacy of the standard carotid endarterectomy. The work was done at Mubarak Al-Kabeer hospital in the state of Kuwait during a 2-year period from December 11, 2004 to December 10, 2006. All patients were evaluated clinically by history taking, physical examination as well as routine laboratory tests including full blood count, renal functions, liver functions, and serum electrolytes in addition to x-ray chest, ECG and echocardiography. Carotid duplex, Magnetic resonance or CT-angiography, computed tomography brain scans were carried out in all patients. Carotid angiography was performed in 4 cases [17.3%] where there was a doubt or misinterpretation between the results of carotid duplex and carotid MRA or CT angio. The indications for carotid endarterectomy [CEA] were: internal carotid artery [ICA] stenosis of 70% or more associated with: nondisabling stroke in 10 patients [43.4%], and recurrent transient ischaemic attacks [TIAs] in 13 patients [56.2%]. In 17 patients [73.9%] CEA was performed under local anaesthesia, while in 6 patients [26%] it was performed under general anaesthesia. Temporary Carotid shunts were used in 7 patients [30.4%] to ensure blood supply to the brain during the procedure. The arteriotomy was closed with a PTFE patch in 13 patients [56.2%] due to small diameter of ICA. In the remaining 10 patients [43.4%] primary closure was done. Post-operative follow-up of the patients was done at 1, 3, 6, 9, and 12 months and every 4 months thereafter based on repeated clinical examination carotid duplex and MRA for carotids and circle of Willis. During the period of follow up there was no mortality. There were two cases [8.6%] of ipsilateral stroke. The first case [4.3%] had nondisabling stroke and the 2nd [4.3%] had major stroke. Wound haematoma occurred in one patient only [4.3%]. Restenosis [stenosis of the lumen diameter of ICA 50% or more] was found at carotid duplex scanning in one patient [4.3%] and occurred 3 months after surgery. CEA is now the method of choice in the treatment of symptomatic severe carotid artery stenosis [70-99%]. It is easy and effective procedure for the prevention and / or minimization of the incidence of subsequent stroke

Endoscopic Trans-thoracic sympathectomy in the treatment of primary palmar hyperhidrosis: results and complications

This study aimed to evaluate the results of primary palmer hyperhidrosis by using endoscope transthoracic sympathectomy with particular reference to the complication, the immediate and long term effectiveness of treatment and patient satisfaction with the endoscope results. Twenty patients with bilateral primary hyperhidrosis were treated by endoscopic transthoracic sympathectomy on both sides. When the stellate ganglion is uniquely identified by a pad of fat covering it above the head of the first rib, a diathermy hook used to confirm identification by palpating the sympathetic chain and rolling the nerves over the ribs. The 2nd, 3rd and 4th ganglia were cut and preserved for histopathological examination. All patients were relieved of their symptoms except the left side of a female patient [aged 26 years and treated by open surgical method]. Compensatory hyperhidrosis was the only significant side effect and reported in sixty five%. There was no mortality or major complications. Endoscopic transthoracic sympathectomy is safe-easy, reliable and effective way in the treatment of patients with primary palmer hyperhidrosis

Prophylaxis by low molecular weight heparin against early thrombosis following infrainguinal arterial bypasses [small letters]

This study aimed to evaluate the preoperative prophylaxis by low molecular weight heparin [enoxaparin] on early graft potency after infrainguinal arterial bypass surgery. The study was done at El-Hussein University Hospital during a 2-year period from August 31 1999 to July 31 2001. The 30 patients with critical chronic lower limb ischemia scheduled to undergo bypass surgery from the groin to a distal site were divided into two groups: Group A included 15 patients who received low molecular weight heparin [enoxaparin] at a dose of 40 mg subcutaneously [SC] on the day before surgery and the same dose was repeated SC every evening for 7 days and group B which is the control group included 15 patients who did not receive the drug. Patients in both groups were evaluated for graft patency at the first postoperative day, one month and at 3 months following bypass surgery. A total of 30 infrainguinal arterial reconstructive surgery was performed, 17 were femoropopliteal bypass above the knee joint, 9 femoropopliteal below the knee and 4 femorotibial bypasses. 22 of these bypass procedures were performed by using prosthetic grafts and 8 were performed by using autogenously vein grafts. In group A, the patency rate at the first postoperative day [one week, one month and after 3 months] following surgery was 93.3%, 86.7%, 80% and 73.3%, respectively. While, the patency rate in group B [control group] was 86.7%,73.3%,66.7% and 46.4%, respectively. The perioperative complications in group A were bleeding [13.3%], myocardial infarction [6.7%] and death [6.7%]. While in group B, these complications included myocardial infarction [6.7%] and death [6.7%]. Low molecular weight heparin is effective on 90 days femorodistal graft patency, but re-evaluation of its efficacy for longer duration should be carried out

Outcome of the above knee femoro-popliteal prosthetic bypasses in patients with chronic lower limb ischaemia

This retrospective study was designed on 20 patients [16 men and 4 women] with critical chronic lower limb ischaemia to ascertain the effectiveness of the polytetrafluoroethylene prosthetic grafts [PTFE grafts] as regard to predictors of success or failure as well as long term patency in patients who underwent above-knee femoropopliteal bypasses during the last 5-years. The study was conducted on 24 limbs in 20 patients. The indication for operation was critical limb ischaemia in 85% of cases and incapacitating claudication in 15% of them. The patients were evaluated clinically, haemodynamically and by imaging techniques. The postoperative follow-up was based on repeated investigations at 1, 3, 6, 9, 12 and 24 months after operation. The 2-, 4 - and 5- year patency rates were 59%, 45% and 40%, while the 2-, 4- and 5- year limb salvage rates were 74%, 63% and 57%. Major amputation was required in 6 limbs [25%]; below-knee in 4 limbs [67%] and above-knee in 2 limbs [33%]. The outcome of above-knee femoropopliteal PTFE bypass grafts was essentially affected by presence of diabetes, poor distal run off, diminished outflow rate as well as multiplicity of the lesions and the severity of each