Inadvertent subclavian artery cannulation: endovascular repair using a collagen closure device-report of two cases and review of the literature.

Inadvertent line insertion into the subclavian artery is an uncommon complication of subclavian venous catheterisation, and its timely recognition is vital to minimise risk of harm to the patient. We describe the radiographic, computed tomographic (CT), and angiographic findings in two patients and illustrate the subsequent endovascular management using collagen vascular closure devices.

Do patients undergoing renal revascularization outside of the ASTRAL trial show any benefit? Results of a single-centre observational study.

INTRODUCTION/OBJECTIVES: Though recent research has concluded that revascularization of atherosclerotic renal artery stenosis has no benefit for most patients, negative findings of the Angioplasty and STent for Renal Artery Lesions (ASTRAL) trial have been criticized in professional fora. Aim of the current study was to determine whether patients undergoing renal revascularization outside of ASTRAL showed any benefit. If so, could we determine a patient group that would benefit from intervention? METHODS: Patients undergoing renal revascularization outside of the ASTRAL trial between 2003 and 2007 at our institution were reviewed. The primary comparison was the rate of decline of renal function based on individual reciprocal creatinine plots for the periods leading up to and following revascularization. Those who showed any improvement in the mean slope were compared to those with a negative or neutral response. RESULTS: One hundred and twenty-seven patients underwent renal revascularization outside of ASTRAL. The majority [79 (62%)] showed some improvement in the rate of change in renal function, though overall this failed to reach statistical significance. Those who responded positively tended to be declining faster prior to intervention; they were less likely to require RRT (6 versus 29%), and if they did, it was significantly later (3.6 versus 0.7 years). Mortality was, however, similar in both groups. Subgroup analysis was undertaken of patients in whom kidney function was rapidly deteriorating prior to revascularization. The rate of change in this group showed a more sizeable improvement (P = 0.05). Nonetheless, a similar proportion of both groups required RRT and there was no evidence of improvement in overall mortality. CONCLUSION: In keeping with ASTRAL's findings, our use of renal revascularization has produced no demonstrable benefit overall. There was a suggestion of benefit in patients with rapidly declining renal function in terms of delaying the need for renal replacement therapy, but improvements in cardiovascular outcomes have yet to be proven.

Endovascular simulator is of benefit in the acquisition of basic skills by novice operators.

PURPOSE: To determine whether an electronic endovascular simulator exhibited "construct validity," that is, the ability to differentiate between novice and experienced operators of differing levels of experience, and whether training on the simulator led to improved performance, thereby indicating "instructional effectiveness" for basic endovascular tasks. MATERIALS AND METHODS: Two separate experiments were performed by using an electronic endovascular simulator. In the first experiment, which was performed to investigate construct validity, the performance of four experienced operators and four novice radiology trainees was compared by using three objective outcome measures. In the second experiment, performed to investigate instructional effectiveness, the authors observed the performance of 14 novice operators before and after training on the device by using similar objective outcome measures as well as subjective measurement of performance from operator and supervisor. RESULTS: In the first experiment, one of the three simulator-derived objective outcome measures for the two subject groups was statistically significant and the other two approached statistical significance. In the second experiment, two of the three objective criteria and all subjective assessments of performance criteria showed a statistically significant improvement. CONCLUSIONS: The results indicate that the endovascular simulator exhibits both construct validity and instructional effectiveness for trainees at an early stage in their acquisition of these skills and support its use in the acquisition of basic endovascular skills.

Use of a peripherally inserted central catheter as a conduit for central venous access across thrombosed great veins.

This report describes a technique of inserting an implantable venous access port (portacath) through a thrombosed and occluded vein employing a pre-existing peripherally inserted central catheter (PICC) as the route of access. The PICC was used as a conduit for venous access in a way that has not been described previously in the literature. This procedure was performed in a young patient with cystic fibrosis in an effort to prevent the use of his virgin contralateral veins, which might be used in the future.

Endovascular treatment for traumatic popliteal artery pseudoaneurysms after knee arthroplasty.

Trauma to the popliteal artery is a recognized complication of knee arthroplasty (total knee arthroplasty). It can present in a variety of ways, one of which is the development of popliteal artery pseudoaneurysm. We report the successful endovascular management of 2 patients who developed popliteal artery pseudoaneurysms following total knee arthroplasty using covered stent grafts. From presented evidence, endovascular therapy is a safe treatment modality and it appears to be a viable alternative to open surgery.

Primary cutting balloon angioplasty for treatment of venous stenoses in native hemodialysis fistulas: long-term results from three centers.

AIM: To evaluate the technical success and patency rates following primary cutting balloon angioplasty for venous stenoses in native dialysis fistulas. METHODS: Forty-one patients (26 men, 15 women; age range 26-82 years, average age 59 years) underwent 50 (repeat procedures in 9 patients) primary cutting balloon (PCB) angioplasty procedures in three institutions by three primary operators. The indication was primary stenosis in 21 patients, recurrent lesions in 15, and immature fistulas in 5. A PCB was used alone in 17 cases, but was followed by a larger standard balloon in 33 cases. Follow-up included ultrasound, flow analysis and urea reduction ratio, and ranged from 2 to 30 months (mean 14 months). RESULTS: The technical success rate was 98%. All procedures were relatively painless. Two PCBs burst and 4 leaked, but without causing any morbidity. Nineteen fistulas were still working at last follow-up. Primary patency rates at 6, 12, and 24 months using Kaplan-Meier analysis were 88%, 73%, and 34%, respectively, and the primary assisted patencies were 90%, 75%, and 50%, respectively. CONCLUSION: PCB angioplasty has high technical success and low complication rates. The long-term patency rates are favorable for PCB angioplasty and compare favorably with other series.

Removal of a permanent IVC filter.

Inferior vena cava (IVC) filters are increasingly used for prevention of life-threatening pulmonary emboli in patients who have contraindications to anticoagulation therapy. We report a case of the removal of a permanent IVC filter, which was inadvertently inserted due to an incorrect ultrasound report.

Failed retrieval of potentially retrievable IVC filters: a report of two cases.

Retrievable inferior vena cava filters are being increasingly used for the prevention of life-threatening pulmonary emboli in patients who have temporary contraindications to anticoagulation therapy. We report two cases of failure to remove these devices.

A nurse led peripherally inserted central catheter line insertion service is effective with radiological support.

AIM: Peripherally inserted central catheters (PICC) are increasingly used as a route of chemotherapy administration. Our aims were to assess a collaborative approach to PICC placement, with radiological support for a nurse led line insertion service in a minority of cases, and to determine whether PICC provided a safe and reliable method of chemotherapy administration. MATERIALS AND METHODS: Prospective data on 100 consecutive patients undergoing PICC placement for chemotherapy were collected. Lines were inserted by ward based nurses or under ultrasound guidance by radiologists. End points were successful completion of treatment or patient death. RESULTS: One hundred and forty-four lines were placed for 118 courses of chemotherapy. 107 (74%) were placed by nurses and 37 (26%) by radiologists. Ninety-five percent of patients completed therapy with either one or two lines. Seventy percent of lines were removed on achieving the primary end points. In two additional patients PICC could not be placed radiologically. Twelve patients were unable to complete treatment with PICC alone, nine of these required an alternative administration route. The catheter related sepsis rate was 4.9%. CONCLUSION: The majority of PICC can be successfully placed by trained nurses, reserving image guidance only for more difficult cases. PICC have an acceptable complication profile, and decrease the need for tunnelled central lines.