Papilledema Secondary to Barotrauma in a Young Adult With Severe Status Asthmaticus With Ventilatory Failure, Pneumothorax, and a Complex Clinical Course.

Intubation and mechanical ventilation are common therapeutic interventions in intensive care unit settings. Barotrauma is a known complication of using positive pressures in a tissue defined by extra alveolar air in locations where it is not generally found in patients receiving mechanical ventilation. Several clinical manifestations of barotrauma include pneumothorax, subcutaneous emphysema, pneumoperitoneum, pneumomediastinum or pneumopericardium, air embolization, and hyperinflated left lower lobe. However, papilledema is an unreported and uncommon complication we observed in one of our patients, making it a unique presentation. We present the case of a young male patient intubated for asthma exacerbation requiring mechanical ventilation with subsequent development of papilledema. Our case report highlights the importance of knowing this rare complication of barotrauma as early commencement of lung-protective strategies will help prevent it.

Partial aneurysmectomy for salvage of autogenous arteriovenous fistula with complicated venous aneurysms.

OBJECTIVE: One complication of autogenous arteriovenous fistula (AVF) for hemodialysis is the formation of a venous aneurysm (VA). The treatment of massive aneurysmal AVF generally involves ligation or resection with the use of prosthetic interposition. Partial aneurysmectomy, with or without reduction venoplasty, has been suggested to treat such a complicated AVF to maintain an all-autogenous access. The purpose of this study was to describe these procedures and examine their outcomes. METHODS: From January 2008 to May 2012, 14 patients (64% males) with complicated VAs were treated by partial aneurysmectomy with reduction venoplasty for a diffusely dilated venous segment. Patients with an infected aneurysm or central vein stenosis were not included. The surgical technique and the postoperative outcome were described. RESULTS: Patients were a mean age of 37.2 ± 12.2 years. Twenty-five aneurysms and four diffusely dilated segments (7, 10, 15, and 21 cm in length) were treated. Four patients (29%) presented with one aneurysm, nine (64%) with two aneurysms, and one (7%) with three aneurysms. The main clinical indications for intervention were skin necrosis and erosion with imminent danger of bleeding in nine (64%), stenosis related to aneurysm in one (7%), and high flow associated with multiple aneurysms or massive diffuse venous dilatation in four (29%). The AVFs were a mean age of 42.4 ± 8.8 months and the VAs were a mean age of 16.2 ± 4.2 months at the time of partial aneurysmectomy. The mean aneurysm diameter was 5.3 ± 1.6 cm. The procedures were successful in all patients. The mean operative time was 180.3 ± 51.5 minutes (range, 90-245 minutes), and the mean hospital stay was 2.5 ± 1.2 days. In five patients, a sufficient usable portion of the AVF remained for cannulation and was punctured the day after the procedure; in the remaining nine patients, a tunneled hemodialysis catheter was inserted. The AVFs remained patent, without recurrent aneurysms, and were used continuously for dialysis throughout the follow-up periods, which were a mean of 30.4 ± 14.4 months (range, 6-48 months). Two patients with functioning AVFs died of causes that were not related to the aneurysmectomy procedure. CONCLUSIONS: Partial aneurysmectomy is a simple and effective intervention for managing aneurysm-associated complications. It offers the ability to maintain the benefits of an autogenous access while conserving future dialysis sites. Partial aneurysmectomy is recommended as a first-line choice for managing aneurysm-associated complications.

Blunt popliteal artery injury with complete lower limb ischemia: is routine use of temporary intraluminal arterial shunt justified?

OBJECTIVE: Complete lower limb ischemia as a result of blunt popliteal artery injury is associated with the highest morbidity and amputation rates among all of the peripheral vascular injuries. The purpose of this study was to determine the possible benefits of routine use of a temporary intraluminal arterial shunt in patients with complete limb ischemia from blunt popliteal trauma. PATIENTS AND METHODS: Over 3 years seven blunt popliteal artery injuries with complete lower limb ischemia were managed with insertion of a shunt at the initial phase of the operation. Data from these procedures was analyzed and compared with retrospectively collected data for 10 injuries with complete ischemia treated without shunts during the preceding 5 years. RESULTS: Mean injury severity score and mangled extremity severity score were 9.3 +/- 3.49 and 5.7 +/- 0.95, respectively, in the shunt group, and 9.9 +/- 3.57 and 5.9 +/- 0.56, respectively in the non-shunt group. Mean ischemic time was 244.3, 24.3, and 268.6 minutes, respectively, for preoperative, intraoperative, and total ischemic time in the shunt group, and 273, 56.5, and 329.5 minutes in the non-shunt group. The difference was significant for intraoperative (P <.001) and total (P <.05) ischemic time. In the entire group, 92.8% of patients with total ischemic time greater than 4 hours underwent fasciotomy, 100% required repeat operation, and 57.1% had complications and required fasciotomy wound debridement. All patients (100%) with ischemic time greater than 6 hours required amputation, compared with no patients with ischemic time less than 5 hours. One patient in the shunt group (14.3%) experienced one fasciotomy wound complication (11.1%), compared with seven patients in the non-shunt group (70%) had 8 complications (88.9%) (P <.05). Mean number of repeat operations was 0.8 +/- 1.06 in the shunt group, and 1.9 +/- 0.73 in the non-shunt group (P <.05). One patient in the shunt group (14.3%) required fasciotomy wound debridement, compared with seven patients in the non-shunt group (70%; P <.05). Mean hospital stay was 14.4 and 23 days, respectively, in the shunt and non-shunt groups (P <.05). Four limbs in the non-shunt group (40%) required amputation, compared with 100% limb salvage in the shunt group. CONCLUSION: Temporary arterial shunting after blunt lower limb trauma significantly reduces total ischemic time, complications, repeat operations, amputation, and hospitalization. I recommend routine use of shunts in blunt popliteal artery injuries with complete lower limb ischemia.

Brachiobasilic arteriovenous fistula: different surgical techniques and their effects on fistula patency and dialysis-related complications.

OBJECTIVE: Easy access to the vascular system is vital in patients with chronic renal failure undergoing long-term hemodialysis. Such patients often require multiple operations, and options for secondary or tertiary access procedures become increasingly limited. Brachiobasilic arteriovenous fistula offers excellent access in such difficult cases and is increasingly preferred over prosthetic grafts. Many surgical techniques have been described to create such fistulas. The purpose of this study was to determine the difference in long-term patency and dialysis-related complications among various techniques. METHODS: Seventy brachiobasilic arteriovenous fistulas were constructed in 70 patients. This was the secondary or tertiary access in 88.6% of patients. The basilic vein was transposed in 30 patients and elevated in 40 patients; twenty veins were elevated with a one-stage technique, and 20 were elevated with a two-stage (delayed elevation) technique. RESULTS: The early failure rate was 5.7% in the entire group. Sixty-six fistulas (94.3%) were successfully used for dialysis. Mean follow-up was 25.8 months (range, 4-36 months). Four fistulas (5.7%) required additional procedures during follow-up, 2 in the transposed vein group and 2 in the elevated vein group. Cumulative secondary patency rate, measured with the Kaplan-Meier survival method, was 86.7%, 90%, and 84.2% at 1 year for the transposed, one-stage, and two-stage elevation procedures, respectively, compared with 82.8%, 70%, and 68.4% at 2 years. The difference was statistically nonsignificant. Forty-two complications developed in 29 (43.9%) fistulas. Thirteen fistulas (19.7%) had more than one complication. Twelve complications in 10 fistulas (35.7%) were recorded in the transposition group, 15 complications in 9 fistulas (47.4%) in the one-stage elevation group, and 15 complications in 10 fistulas (52.6%) in the two-stage elevation group. The total complication rate was higher in the elevated fistulas (71.4% vs 28.6%); the difference was statistically highly significant (P <.001). The most common complication was arm edema (21.2%; n = 14), followed by puncture site-related hematoma (16.7%; n = 11) and thrombosis (16.7%; n = 11). Hematoma was statistically more common (P <.05) in the elevated vein group (26.3% vs 3.6%). The difference in thrombosis between the transposition and elevation groups (23.7% vs 7.1%) was not significant. Hematoma preceded thrombosis in 63.7% (7 of 11) of the fistulas, and it was the major predisposing factor for fistula failure. Transposed vein was easier to manage by dialysis staff. All nurses were satisfied with the transposed veins, but only 53.3% were satisfied with the elevated veins; the difference was statistically highly significant (P <.001). CONCLUSION: Available techniques for creating brachiobasilic arteriovenous fistula are associated with good patency rate, and most related complications can be treated conservatively without loss of the fistula. Among the various procedures, transposition has a lower complication rate and is favored by the dialysis staff dealing with such fistulas.