Does a distal perfusion cannula reduce ischaemic complications of extracorporeal membrane oxygenation?

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) provides support to patients with severe but reversible cardiac or pulmonary failure. Vascular complications of ECMO are well recognized. METHODS: We performed a retrospective review of 70 patients (mean age 48 years; 15-85) who received peripheral veno-arterial ECMO from 2004 to 2010 in a single centre. For statistical analysis, chi-squared test and multivariate binary logistic regression analysis were used to assess for association between response variables (i.e. limb ischaemia, ECMO site bleeding and deep vein thrombosis (DVT)) and possible predictive variables. RESULTS: There were 14 (20%) cases of acute limb ischaemia with no statistically significant relationship between acute limb ischaemia and independent variables. Thirty-three patients received distal limb cannulas (47%). There was no statistically significant association between limb ischaemia and presence of distal limb cannula (P = 0.8). Multivariate binary logistic regression analysis identified insertion by cutdown as a predictor of lower probability of insertion site bleeding (n = 12, odds ratio 0.24, P = 0.04). Seven cases of DVT were identified; multivariate binary logistic regression analysis identified insertion by cutdown (odds ratio 0.08, P = 0.03) and days of ECMO less than five (odds ratio 0.08, P = 0.04) as predictive factors for reduced rates of DVT. CONCLUSION: Ischaemic complications of ECMO are common and occur despite the presence of a distal limb-perfusing cannula; however in our study the distal limb cannula was a limb-salvaging intervention in six patients. Prolonged time on ECMO is a risk factor for DVT, and a high index of suspicion must be maintained. Percutaneous insertion was associated with higher rates of bleeding and DVT.

Percutaneous endovascular repair of popliteal artery aneurysms.

BACKGROUND: To evaluate percutaneous endovascular repair of popliteal artery aneurysms (PAAs) using self-expanding covered stent grafts. METHODS: A retrospective record review of consecutive patients who underwent percutaneous endovascular PAA repair across 2 Australian centers between April 2009 and May 2012 was performed. RESULTS: We report 16 patients (mean age: 77.3; 93% men) with PAA in 20 limbs who underwent percutaneous endovascular repair using self-expanding covered stent grafts. The mean aneurysm diameter was 3 cm (range: 2-5.1 cm). Ultrasound-guided percutaneous antegrade access was used in all cases: 16 superficial femoral artery punctures and 4 common femoral artery punctures. The mean number of runoff vessels per limb was 1.84 (42%, 1 vessel; 32%, 2 vessels; and 26%, 3 vessels). Technical success was 100%. A mean number of 1.82 stents were deployed in each limb (range: 1-3). The mean stent diameter was 8.84 (range: 6-13). The median follow-up time was 12 months (range: 0-24 months). Primary patency of 85% and secondary patency of 90% were achieved in our study. The limb loss and mortality rate were 5% both in a patient with an undiagnosed prothrombotic condition. Puncture site complications were seen in 1 patient (5%) who had a bleeding diathesis. CONCLUSIONS: Percutaneous endovascular repair of PAA using self-expanding stent grafts can be safely performed and achieved good results achieved in most patients.

Early Australasian experience with branched endovascular thoracoabdominal aortic aneurysm repair.

INTRODUCTION: Endovascular technology can now support total endovascular thoracoabdominal aortic aneurysm repair with branches maintaining visceral and renal perfusion thus avoiding the need for massive open surgery. High-volume centres have reported encouraging results. We report our Australasian experience of 10 cases including the first-in-man 'off-the-shelf' graft. METHODS: Ten consecutive endovascular repairs performed with prospective data collection have been retrospectively analysed. RESULTS: Six men and four women with an average age of 72.4 years (range 55-85) were treated between 2009 and 2012. The mean aneurysm diameter was 7 cm (range 4.8-10.0) with aneurysms across all five Crawford classifications. One hundred per cent procedural technical success was achieved and all branches and fenestrations were patent at a median follow up of 12 months. In total, 30 branches were utilized together with seven fenestrations. One death from respiratory failure occurred on day 30 without endograft problems and there were two late aneurysm related deaths. Three patients experienced spinal cord ischaemia and one patient experienced two separate late endoleaks. Six patients had successful endografts and remain alive and well. DISCUSSION: For experienced endovascular surgeons working with a proctor 100% technical success in graft deployment is achievable. Endovascular skills alone do not guarantee long-term success; our results demonstrate the need for careful patient selection, the danger of spinal cord ischaemia and the potential for endoleaks.

Endovascular repair of a ruptured abdominal aortic aneurysm in a patient with bilateral iliac dissections.

BACKGROUND: The presentation of a ruptured fusiform abdominal aortic aneurysm (AAA) co-occurring with bilateral iliac dissections is extremely rare. Endovascular repair of ruptured AAA is an accepted treatment modality for suitable patients; however, this approach may be complicated by the presence of iliac arterial pathology. METHODS AND RESULTS: We report the case of a 66-year-old man who presented with a ruptured AAA. Preoperative imaging demonstrated bilateral iliac artery dissections in addition to the ruptured AAA. We describe the technical aspects of the combined endovascular and open surgical repair required to manage this complex presentation. CONCLUSION: The combined presentation of ruptured AAA and bilateral iliac dissections has not been previously reported. Successful repair can be achieved using a combined endovascular and open surgical approach.

Using bilateral iliac branch devices for endovascular iliac aneurysm repair.

INTRODUCTION: The endovascular repair of bilateral iliac aneurysms using bilateral Iliac Branch Devices (IBDs) has been infrequently performed and reported.We aim to describe this technique and report on the results of our case series. METHODS: Three different device designs are available. The procedural options include a totally transfemoral approach, or a combined transfemoral and brachial approach. Clinical records for patients who have had this procedure were reviewed. RESULTS: The indications for the technique include bilateral common iliac artery aneurysm repair, with or without concomitant abdominal aortic aneurysm repair. Considerations include the timing of main body endovascular aortic aneurysm repair (EVAR) device introduction, the use of a proximal access site and the type of IIA stent-graft that is used. Between 2007 and 2010, six patients had bilateral IBD implantation. All patients required an EVAR main body device in addition to bilateral IBDs. Eighty-three per cent were males, mean age was 73 years. Mean follow up was 15 months. Technical success was obtained in 100% of cases. There was one branch occlusion (8.3%). There were no type I endoleaks. One patient had a type II endoleak. CONCLUSIONS: Bilateral IBDs can be used safely and with excellent rates of technical success and branch patency in appropriately selected patients.

The iliac bifurcation device for endovascular iliac aneurysm repair: indications, deployment options and results at 1-year follow-up of 25 cases.

BACKGROUND: The iliac bifurcation device (William A Cook Australia, Brisbane, QLD, Australia) is a new endovascular device for iliac aneurysm repair. We review the indications for use, device characteristics, deployment options and the results of our case series. METHODS: The most common indication for deployment is endovascular aortic aneurysm repair (EVAR) with common iliac aneurysm repair. The standard deployment sequence can be adapted to increase the utility of the device. Data were collected prospectively. Follow-up was performed with plain X-ray, ultrasound and computed tomography (CT) scan. RESULTS: Between 2004 and 2007, 25 patients had their common iliac artery aneurysm repaired using the iliac bifurcation device. There were 23 male and 2 female patients. Median age was 75 years (range 60-85). The median follow-up was 12 months (range 1-38). Twenty-one procedures were combined with EVAR. The median abdominal aortic aneurysm diameter was 60 mm (range 31-97), and the median common iliac artery aneurysm diameter was 37 mm (range 24-71). Technical success was achieved in 100% of cases. There were no acute branch vessel occlusions. There was one early type I endoleak (4%). There was one death (4%) in the 30-day period post-procedure. There was one late type I endoleak (4%). CONCLUSIONS: The iliac bifurcation device achieves endovascular common iliac artery aneurysm repair with preservation of internal iliac artery flow. There are multiple different applications of the device and complementary deployment techniques. High rates of technical success and low rates of branch vessel occlusion are possible.

Transient ischaemic attack caused by an ingested stingray barb.

A 76-year-old woman reported a fishbone stuck in her throat, but no foreign body was identified. Eight weeks later, she experienced a transient ischaemic attack, and a stingray barb was subsequently removed from the right common carotid artery. To our knowledge, this is the first report of the migration of an ingested stingray barb.

Durability of autogenous vein and polytetrafluoroethylene bypass grafts to the carotid arteries.

BACKGROUND: Bypass for extra-cranial arterial disease is infrequently carried out. We reviewed our experience to determine the outcome of carotid artery grafting using either an autogenous vein or polytetrafluoroethylene (PTFE). METHODS: Details of patients were recorded prospectively as part of a vascular surgical registry. Patients identified from the registry as having carotid artery bypass procedures were classified according to the type of conduit used. Comparison was made between patients with autogenous vein and PTFE grafts. RESULTS: Between 1978 and 2002, 24 patients (13 men and 11 women) mean age 60.0 +/- 13.4 years (range, 20-81 years) underwent 28 bypass procedures (three were bilateral and one was a reoperation). Symptomatic carotid disease was the clinical indication in 20 of 28 procedures (71.4%). Pathological indications included advanced atherosclerosis of the carotid arteries (15), past radiotherapy (4), failed stenting (3), resection of carotid body tumour (2), trauma (1), reoperation on a failed graft (1), carotid aneurysm (1) and iatrogenic carotid occlusion (1). An autogenous vein was used in 16, PTFE in 11 and autogenous artery in 1 of the patients. Using the Kaplan-Meier method, the overall patient cumulative 5-year survival was 84% and cumulative 5-year stroke-free survival was 93%. The combined perioperative stroke and mortality rate was 7.1%. Two patients had transient ischaemic attacks (7.1%), one had cranial nerve palsies (3.6%) and one required reoperation for bleeding (3.6%). Five-year cumulative graft primary patency using the Kaplan-Meier method was 74% for PTFE grafts and 92% for autogenous vein grafts (P = 0.37). CONCLUSION: Carotid artery bypass is a safe and a useful treatment option for complex extra-cranial arterial disease. Either PTFE or autogenous veins may be used as conduits.

Laparoscopic versus open ileocolic resection for Crohn's disease.

OBJECTIVE: Laparoscopic ileocolic (LI) resection for Crohn's disease has several potential advantages over the traditional open technique. The objective of this study was to compare early surgical outcomes in patients having laparoscopic versus open ileocolic resections for Crohn's disease. METHODS: Data collected prospectively from 21 patients having LI resection for Crohn's disease between 1995 and 2001 were compared to data from 19 patients having open ileocolic resection for Crohn's disease between 1990 and 1995. RESULTS: Patients in both groups had similar ages, sex distribution, and rates of previous abdominal surgery. Mean operating time was not significantly different between the groups. There was a nonsignificant trend to less postoperative analgesic requirement in the laparoscopic group. Resumption of liquid (P <.001) and solid (P =.01) diet, return of bowel function [flatus (P =.008), feces (P =.008)] and time to discharge (P =.001) all occurred significantly more quickly in the laparoscopic group. There was no difference in the rates of morbidity between the two groups. CONCLUSIONS: LI resection for Crohn's disease appears to be safe and has comparable if not superior results to open surgery in the short term.