ABSTRACT
Upper extremity aneurysms are relatively infrequent when compared to other vessels in the body. However, a combination of factors occurring following arteriovenous fistula (AVF) ligation can lead to dilation of the brachial artery. Periodic follow-up after AVF creation can help prevent complications. We report a case of an immunosuppressed, patient with renal transplant who presented with delayed onset digital ischemia following ligation of a remotely created brachial artery-cephalic vein fistula.
Subject(s)
Aneurysm/etiology , Arteriovenous Shunt, Surgical , Brachial Artery/surgery , Fingers/blood supply , Ischemia/etiology , Renal Insufficiency/therapy , Upper Extremity/blood supply , Aneurysm/diagnosis , Aneurysm/surgery , Brachial Artery/diagnostic imaging , Humans , Immunocompromised Host , Immunosuppressive Agents/adverse effects , Ischemia/diagnosis , Ischemia/surgery , Kidney Transplantation/adverse effects , Ligation/adverse effects , Male , Middle Aged , Radiography , Renal Dialysis , Reoperation , Risk Factors , Saphenous Vein/transplantation , Treatment Outcome , Veins/surgeryABSTRACT
Congenital anomalies of the inferior vena cava (IVC) are rare, but recognized, causing deep venous thrombosis. We present a case of a 50-year-old patient with trauma who suffered an intracranial hemorrhage secondary to a fall while on anticoagulation for deep vein thromboses. Venous return from the lower extremities was determined to be through dilated lumbar venous collaterals into the azygous and hemiazygous systems. A second interesting anatomic finding was a hypoplastic left kidney.
Subject(s)
Accidental Falls , Anticoagulants/therapeutic use , Intracranial Hemorrhage, Traumatic/etiology , Kidney/abnormalities , Vascular Malformations/complications , Vena Cava, Inferior/abnormalities , Venous Thrombosis/drug therapy , Warfarin/therapeutic use , Acute Kidney Injury/etiology , Azygos Vein/pathology , Azygos Vein/physiopathology , Collateral Circulation , Dilatation, Pathologic , Humans , Intracranial Hemorrhage, Traumatic/diagnosis , Intracranial Hemorrhage, Traumatic/physiopathology , Magnetic Resonance Angiography , Male , Middle Aged , Phlebography , Regional Blood Flow , Vascular Malformations/diagnosis , Vascular Malformations/physiopathology , Vena Cava, Inferior/diagnostic imaging , Vena Cava, Inferior/physiopathology , Venous Thrombosis/diagnosis , Venous Thrombosis/etiology , Venous Thrombosis/physiopathologyABSTRACT
BACKGROUND: Hepatic angiography (HA) and hepatic angioembolization (HAE) are increasingly used to diagnose and treat intrahepatic arterial injuries. This study was performed to review indications, outcomes, and complications of HA/HAE in blunt trauma patients who underwent HAE as adjunct management of hepatic injury. METHODS: A retrospective review of consecutive cases of HA/HAE at a Level I trauma center during an 8-year period. Data include demographics, physiologic condition, liver injury grade, HA/HAE indications, outcomes, morbidity, and mortality. RESULTS: Seventy-nine patients underwent diagnostic HA; 31 (39%) had subsequent HAE. Fifty-eight hemodynamically stable patients had computerized axial tomographic (CT) scan followed by HA. HA was performed for contrast blush on CT in 30 (52%) of 58 patients, high-grade liver injury in 4 (7%), subsequent hemodynamic instability in 15 (27%), and angiography planned for other purpose in 9 (17%). HA confirmed arterial injury and led to HAE in 50% of patients with contrast blush on CT or high-grade liver injury. HA was negative when performed for hemodynamic instability or for other primary purposes. Twenty-one hemodynamically unstable patients underwent emergent laparotomy followed by postoperative HA with 11 (50%) requiring HAE. Overall mortality in HAE group was 16%, and liver-related morbidity was 29% usually presenting as gallbladder or liver necrosis. CONCLUSION: HA/HAE should be used when CT scan suggests associated intrahepatic arterial or high-grade injury in the management of hepatic injuries and should also be considered after laparotomy and perihepatic packing to control inaccessible intrahepatic hemorrhage. Mortality related to HAE is uncommon, but morbidity occurs frequently.
Subject(s)
Embolization, Therapeutic , Hepatic Artery/injuries , Liver/injuries , Wounds, Nonpenetrating/therapy , Adolescent , Adult , Aged , Aged, 80 and over , Child , Child, Preschool , Contraindications , Embolization, Therapeutic/adverse effects , Female , Gallbladder/blood supply , Hemodynamics , Humans , Ischemia/etiology , Male , Middle Aged , Retrospective Studies , Wounds, Nonpenetrating/physiopathology , Young AdultABSTRACT
BACKGROUND: Cirrhosis as an independent predictor of poor outcomes in trauma patients was identified in 1990. We hypothesized that the degree of preinjury hepatic dysfunction is, by itself, an independent predictor of mortality. STUDY DESIGN: The trauma registry at our Level I trauma center was queried for all ICD-9 codes for liver disease from 1999 to 2003, and patients were categorized as having Child-Turcotte-Pugh (CTP) class A, B, or C cirrhosis. Data analyzed included age, mechanism of injury, Abbreviated Injury Score (AIS), Injury Severity Score (ISS), Glasgow Coma Score (GCS), hospital length of stay, ventilator days, procedures performed, transfusion of blood products, admission lactate, base deficit, and mortality. Trauma Related Injury Severity Score (TRISS) methodology was used to calculate the probability of survival. Outcomes data were analyzed, and statistical comparison was performed using group t-test. RESULTS: Of the 50 patients meeting study criteria, 31 had alcohol-related cirrhosis, 18 had a history of hepatitis C, and 1 had cryptogenic cirrhosis. Twenty (40%) met CTP A classification, 16 (32%) met CTP B criteria, and 14 (28%) had CTP class C cirrhosis. One death occurred in the CTP A and B groups. Comparison between the five survivors and nine nonsurvivors from CTP class C showed no statistical significance in terms of age, ISS, TRISS, or GCS. CONCLUSIONS: The mortality rate for class C cirrhotic patients posttrauma continues to be higher than that predicted by TRISS, although patients with less severe hepatic dysfunction do not appear to have significantly lower than predicted survival. The degree of hepatic dysfunction remains an independent predictor of mortality and CTP C criteria must be considered when determining outcomes for patients posttrauma.
Subject(s)
Liver Cirrhosis/mortality , Wounds and Injuries/mortality , Adult , Aged , Aged, 80 and over , Blood Transfusion , Humans , Liver Cirrhosis/classification , Liver Cirrhosis/complications , Male , Middle Aged , Survival Rate , Trauma Severity Indices , Wounds and Injuries/classification , Wounds and Injuries/complications , Wounds and Injuries/surgeryABSTRACT
Missile embolism to the pulmonary artery is a rare event. We present a complicated case of missile embolism from the inferior vena cava to the pulmonary artery. The case illustrates the potential pitfalls in the management of these patients.
