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1.
Vasc Endovascular Surg ; 58(2): 235-239, 2024 Feb.
Article in English | MEDLINE | ID: mdl-37732898

ABSTRACT

Paget-Schroetter Syndrome (PSS) is a form of upper extremity deep vein thrombosis (DVT) caused by the external compression of the subclavian vein at the thoracic outlet. Here we describe a complex PSS case in a 43-year-old female who experienced multiple recurrent DVTs and a right-sided hemothorax following two continuous aspiration thrombectomy procedures and a first rib resection. Rapid and complete symptom resolution was achieved with the InThrill Thrombectomy System (Inari Medical), a novel, thrombolytic-free, percutaneous mechanical thrombectomy device that removed all recurrent acute and subacute thrombus in a single session without significant blood loss.


Subject(s)
Upper Extremity Deep Vein Thrombosis , Venous Thrombosis , Female , Humans , Adult , Upper Extremity Deep Vein Thrombosis/diagnostic imaging , Upper Extremity Deep Vein Thrombosis/etiology , Upper Extremity Deep Vein Thrombosis/therapy , Treatment Outcome , Thrombectomy/adverse effects , Venous Thrombosis/diagnostic imaging , Venous Thrombosis/etiology , Venous Thrombosis/therapy , Subclavian Vein/diagnostic imaging , Subclavian Vein/surgery , Thrombolytic Therapy/adverse effects
2.
Ann Vasc Surg ; 29(5): 927-33, 2015 Jul.
Article in English | MEDLINE | ID: mdl-25757993

ABSTRACT

BACKGROUND: Vascular steal syndrome related to a dialysis arteriovenous fistula (AVF) can lead to symptoms of distal ischemia, limb loss, digit ulceration, and gangrene. Several complex procedures have been used to augment and restore distal limb perfusion while maintaining a functional AVF. We reviewed our experience in treating AVF-related vascular steal syndrome by simple plication of the initial AVF inflow segment. METHODS: Clinical data of 26 patients (15 men; mean age, 58 years; range, 26-80) with vascular steal syndrome related to their AVF underwent plication during a 36-month period. There were 18 brachial-cephalic AVFs and 8 brachial-basilic AVFs with vein transposition. Relevant clinical variables, imaging studies, and treatment variables were analyzed. RESULTS: Eighty-four percent of patients had hypertension, 62% were diabetics, and 15% had a previous limb or digit amputated. Hand pain, skin ulceration, or gangrene was present in 96%, 15%, and 12% of patients, respectively; 19% of patients had more than one symptom. Twelve (46%) patients had an aortic arch and upper extremity arteriogram, of which 67% showed evidence of arterial disease. One patient required percutaneous balloon-expandable stent treatment of a proximal left subclavian artery stenosis to improve flow. Duplex-derived volume flow measurements of the AVF were obtained with an average flow of 1.95 ± 0.83 L/min. Open repair and venous inflow plication was performed in all 26 patients. Average flow reduction in patients with preoperative and postoperative flow measurements was 0.6 ± 0.5 L/min (P < 0.05). There was a 12% revision rate within 3 months. Symptom resolution was achieved in 92% of patients while maintaining a functioning access out to 1 year. Two remaining patients who did not improve and proceeded to ligation of the AVF. CONCLUSIONS: Surgical plication of the initial AVF inflow segment offers a simple solution to preserve the dialysis access and resolve symptoms related to vascular steal associated with high volume flow through the AVF.


Subject(s)
Arteriovenous Shunt, Surgical/adverse effects , Ischemia/surgery , Renal Dialysis , Upper Extremity/blood supply , Veins/surgery , Adult , Aged , Aged, 80 and over , Arteriovenous Shunt, Surgical/methods , Blood Flow Velocity , Female , Humans , Ischemia/diagnosis , Ischemia/etiology , Ischemia/physiopathology , Male , Middle Aged , Regional Blood Flow , Reoperation , Retrospective Studies , Risk Factors , Time Factors , Treatment Outcome , Ultrasonography, Doppler, Duplex , Veins/diagnostic imaging , Veins/physiopathology
3.
J Vasc Surg ; 61(2): 444-8, 2015 Feb.
Article in English | MEDLINE | ID: mdl-25154565

ABSTRACT

BACKGROUND: Arteriovenous fistula (AVF) aneurysms (AVFAs) can lead to skin erosion, bleeding, difficult access while on hemodialysis, and poor cosmetic appearance. We reviewed our experience in treating patients with aneurysmal dilatation of their AVF. METHODS: We reviewed clinical data of 48 patients (37 men; overall mean age, 55 years; range, 28-85 years) with an AVFA who underwent treatment during a 30-month period. Relevant clinical variables and treatment outcomes were analyzed. RESULTS: All patients underwent a fistulogram, and 90% required percutaneous angioplasty to improve outflow. Fifty-six percent of patients had one stenotic outflow lesion, and 44% had at least two tandem outflow stenoses that required treatment. Open repair with aneurysmorrhaphy was performed in one stage in 64% of patients and in two stages in 36%. A tunneled hemodialysis catheter was required in 11 patients (23%) until the surgically repaired AVF was ready for use again, comprising 10 patients treated with single-stage surgery and only one patient in the staged group. All AVFAs were effectively treated, and patients were able to maintain functional use of their access when healed. CONCLUSIONS: There is a high association of venous outflow stenoses and AVFA. Comprehensive therapy should encompass treatment of any venous outflow stenoses before open AVFA repair. A two-stage repair may decrease tunneled hemodialysis catheter use in patients with multiple aneurysms.


Subject(s)
Aneurysm/surgery , Angioplasty, Balloon , Arteriovenous Shunt, Surgical/adverse effects , Graft Occlusion, Vascular/therapy , Renal Dialysis , Upper Extremity/blood supply , Adult , Aged , Aged, 80 and over , Aneurysm/diagnosis , Aneurysm/etiology , Angioplasty, Balloon/adverse effects , Catheters, Indwelling , Constriction, Pathologic , Dilatation, Pathologic , Female , Graft Occlusion, Vascular/diagnosis , Graft Occlusion, Vascular/etiology , Humans , Male , Middle Aged , Renal Dialysis/instrumentation , Reoperation , Retrospective Studies , Time Factors , Treatment Outcome , Veins/surgery
4.
Thrombosis ; 2014: 649652, 2014.
Article in English | MEDLINE | ID: mdl-24672719

ABSTRACT

Background. Hypercoagulable disorders can lead to deep vein thrombosis (DVT), arterial thrombosis or embolization, and early or recurrent bypass graft failure. The purpose of this study was to identify whether diabetes increased the likelihood of heparin-induced platelet factor 4 antibodies in at risk vascular patients. Methods. We reviewed clinical data on 300 consecutive patients. A hypercoagulable workup was performed if patients presented with (1) early bypass/graft thrombosis (<30 days), (2) multiple bypass/graft thrombosis, and (3) a history of DVT, pulmonary embolus (PE), or native vessel thrombosis. Relevant clinical variables were analyzed and compared between patients with diabetes (DM) and without diabetes (nDM). Results. 85 patients (47 women; age 53 ± 16 years, range 16-82 years) had one of the defined conditions and underwent a hypercoagulable evaluation. Screening was done in 4.7% of patients with early bypass graft thrombosis, 60% of patients were screened because of multiple bypass or graft thrombosis, and 35.3% had a previous history of DVT, PE, or native vessel thrombosis. Of the 43 patients with DM and 42 nDM evaluated, 59 patients (69%) had an abnormal hypercoagulable profile. An elevated heparin antibody level was present in 30% of DM and 12% of nDM patients (chi-squared test P < 0.04). Additionally, DM was associated with a higher likelihood of arterial complications while nDM was associated with a higher rate of venous adverse events (chi-squared test P < 0.003). Conclusions. Diabetes is associated with a higher likelihood of developing heparin-induced antibodies and an increased combined incidence of arterial complications that include early or multiple bypass/graft thrombosis. This finding may influence the choice of anticoagulation in diabetic patients at risk with vascular disease.

5.
J Vasc Surg ; 58(5): 1267-75.e1-2, 2013 Nov.
Article in English | MEDLINE | ID: mdl-24160311

ABSTRACT

BACKGROUND: There has been a marked paradigm shift in the treatment of symptomatic femoro-popliteal disease with a shift from open to endoluminal therapy. The consequence of this shift in therapy is poorly described. The aim of this study is to examine the clinical efficacy of this shift in treatment strategies. METHODS: A database of patients undergoing open (OPEN) and endoluminal (ENDO) intervention for TASC II C and D femoro-popliteal lesions between 1990 and 2010 was retrospectively queried. Kaplan-Meier survival analyses were performed to assess time-dependent outcomes. Factor analyses were performed using a multivariant Cox proportional hazard model for time-dependent variables. RESULTS: A total of 2593 limbs underwent either OPEN or ENDO treatment for symptomatic and anatomically advanced femoro-popliteal disease over a 20-year period. There was a two-fold rise in endovascular interventions between the first and second decade. In the first decade, 80% of the interventions were OPEN, while in the second decade, 61% of the interventions were ENDO. There were equivalent comorbidities in both groups, and survival was also equivalent. Endoluminal therapy was more commonly performed on claudicants. Thirty-day mortality was equivalent, but major morbidity was higher in OPEN compared with ENDO. Cumulative patency was equivalent in both groups with a similar reintervention rate. In contrast, clinical efficacy (freedom from recurrent symptoms, maintenance of ambulation, and avoidance of major amputation) was significantly higher in the OPEN group (P = .002). The presence of critical limb ischemia, diabetes, end-stage renal disease, and poor tibial runoff were predictors of poor anatomic and functional outcomes in both groups. CONCLUSIONS: There has been a marked shift in treatment modality for advanced femoro-popliteal disease with a lowering of the symptomatic threshold for intervention over 2 decades, likely spurred by the ease of endoluminal interventions. Although peri-procedural and anatomic outcomes for both procedures are equivalent, it appears that open surgery carries a superior long-term clinical efficacy. This superiority is negatively influenced by poor preoperative ambulation status, high modified Cardiac Risk Score, worse presenting symptoms, the occurrence of major adverse cardiovascular events, poor tibial runoff, the absence of hemodynamic success, and occlusion of the original bypass.


Subject(s)
Arterial Occlusive Diseases/therapy , Endovascular Procedures , Femoral Artery/surgery , Popliteal Artery/surgery , Vascular Surgical Procedures , Aged , Aged, 80 and over , Amputation, Surgical , Arterial Occlusive Diseases/diagnosis , Arterial Occlusive Diseases/mortality , Arterial Occlusive Diseases/physiopathology , Arterial Occlusive Diseases/surgery , Chi-Square Distribution , Comorbidity , Constriction, Pathologic , Endovascular Procedures/adverse effects , Endovascular Procedures/mortality , Factor Analysis, Statistical , Female , Femoral Artery/physiopathology , Humans , Kaplan-Meier Estimate , Limb Salvage , Male , Middle Aged , Multivariate Analysis , Popliteal Artery/physiopathology , Postoperative Complications/mortality , Postoperative Complications/therapy , Proportional Hazards Models , Reoperation , Retrospective Studies , Risk Factors , Time Factors , Treatment Outcome , Vascular Patency , Vascular Surgical Procedures/adverse effects , Vascular Surgical Procedures/mortality
6.
Ann Vasc Surg ; 27(8): 1182.e9-12, 2013 Nov.
Article in English | MEDLINE | ID: mdl-23988550

ABSTRACT

The decision-making involved in managing type 2 aortic dissections remains challenging despite the advances in endovascular technology. We report a challenging case of a patient presenting with a type 2 aortic dissection and false lumen extension into an infrarenal abdominal aortic aneurysm (AAA). Severe back pain and hypertension were the patient's initial complaints, and dynamic magnetic resonance angiography revealed 1-way pulsatile flow into the AAA sac from the false lumen. This patient underwent endovascular repair with a thoracic and infrarenal aortic endograft, successfully excluding the false lumen and decompressing the infrarenal aneursymal sac. This is a unique presentation of total endovascular repair of a symptomatic type B aortic dissection with a pressurized infrarenal AAA sac from false lumen flow into the sac.


Subject(s)
Aortic Aneurysm, Abdominal/surgery , Aortic Aneurysm, Thoracic/surgery , Aortic Dissection/surgery , Blood Vessel Prosthesis Implantation , Endovascular Procedures , Aged, 80 and over , Aortic Dissection/complications , Aortic Dissection/diagnosis , Aortic Dissection/physiopathology , Aortic Aneurysm, Abdominal/complications , Aortic Aneurysm, Abdominal/diagnosis , Aortic Aneurysm, Abdominal/physiopathology , Aortic Aneurysm, Thoracic/complications , Aortic Aneurysm, Thoracic/diagnosis , Aortic Aneurysm, Thoracic/physiopathology , Aortography/methods , Back Pain/etiology , Blood Vessel Prosthesis , Blood Vessel Prosthesis Implantation/instrumentation , Decompression, Surgical , Endovascular Procedures/instrumentation , Humans , Hypertension/etiology , Magnetic Resonance Angiography , Male , Pulsatile Flow , Regional Blood Flow , Tomography, X-Ray Computed , Treatment Outcome
7.
Ann Vasc Surg ; 27(1): 1-7, 2013 Jan.
Article in English | MEDLINE | ID: mdl-22981018

ABSTRACT

BACKGROUND: Intraoperative rupture of the iliac artery is a serious complication of endovascular aneurysm repair (EVAR), the outcomes of which have changed with increasing experience and improved endovascular tools over the past 2 decades. Over the past 15 years, the incidence and management of iliac rupture has changed as devices have improved and experience has grown. This study reviews our longitudinal experience with this complication. METHODS: All cases of iliac artery rupture during EVAR from 1997 through 2011 were reviewed for presentation, treatment strategies, and outcomes. RESULTS: Iliac artery rupture complicated 20 (3%) of 707 EVARs performed. Sixteen (80%) common and four (20%) external iliac arteries were ruptured. Hypotension (systolic blood pressure: <90 mm Hg) was present in 11 (55%) cases. Five open bypasses were performed (25%), whereas 15 were repaired using an endovascular approach (75%). All open repairs (100%) were associated with postoperative morbidity (one wound infection, four multiorgan system failure), whereas three of the 15 patients (23%) repaired endovascularly experienced postoperative morbidity (cerebrovascular accident, myocardial infarction, line infection). There were no intraoperative deaths. There were four (20%) early deaths in the intensive care unit (<3 days postoperatively), all of which were associated with resection of bilateral hypogastric arteries and were due to complications of pelvic ischemia and/or multiorgan system failure. CONCLUSIONS: Iliac artery rupture remains relatively uncommon but can carry a high morbidity and mortality. As device technology, imaging quality for preoperative planning, and experience level have improved, iliac rupture has become less common, and outcomes in the setting of iliac rupture have significantly improved. Endoluminal management has evolved as the primary treatment strategy. Resection of both hypogastric arteries is associated with mortality from pelvic ischemia, a likely indicator of systemic disease.


Subject(s)
Aortic Aneurysm/surgery , Blood Vessel Prosthesis Implantation/adverse effects , Endovascular Procedures/adverse effects , Iatrogenic Disease , Iliac Artery/injuries , Iliac Artery/surgery , Vascular System Injuries/surgery , Aged , Aged, 80 and over , Aortic Aneurysm/mortality , Blood Vessel Prosthesis Implantation/mortality , Endovascular Procedures/mortality , Female , Hospital Mortality , Humans , Iliac Artery/physiopathology , Kaplan-Meier Estimate , Longitudinal Studies , Male , Middle Aged , Multivariate Analysis , Postoperative Complications/mortality , Retrospective Studies , Rupture , Time Factors , Treatment Outcome , Vascular System Injuries/etiology , Vascular System Injuries/mortality , Vascular System Injuries/physiopathology
8.
J Trauma Acute Care Surg ; 73(3): 625-8, 2012 Sep.
Article in English | MEDLINE | ID: mdl-22929493

ABSTRACT

BACKGROUND: Venous thromboembolism (VTE) is a significant risk in trauma patients. Although low-molecular weight heparin (LMWH) is effective in VTE prophylaxis, its use for patients with traumatic intracranial hemorrhage remains controversial. The purpose of this study was to evaluate the safety of LMWH for VTE prophylaxis in blunt intracranial injury. METHODS: We conducted a retrospective multicenter study of LMWH chemoprophylaxis on patients with intracranial hemorrhage caused by blunt trauma. Patients with brain Abbreviated Injury Scale score of 3 or higher, age 18 years or older, and at least one repeated head computed tomographic scan were included. Patients with previous VTE; on preinjury anticoagulation; hospitalized for less than 48 hours; on heparin for VTE prophylaxis; or required emergent thoracic, abdominal, or vascular surgery at admission were excluded. Patients were divided into two groups: those who received LMWH and those who did not. The primary outcome was progression of intracranial hemorrhage on repeated head computed tomographic scan. RESULTS: The study included 1,215 patients, of which 220 patients (18.1%) received LMWH and 995 (81.9%) did not. Hemorrhage progression occurred in 239 of 995 control subjects and 93 of 220 LMWH patients (24% vs. 42%, p < 0.001). Hemorrhage progression occurred in 32 patients after initiating LMWH (14.5%). Nine of these patients (4.1%) required neurosurgical intervention for hemorrhage progression. CONCLUSION: Patients receiving LMWH were at higher risk for hemorrhage progression. We were unable to demonstrate safety of LMWH for VTE prophylaxis in patients with brain injury. The risk of using LMWH may exceed its benefit. LEVEL OF EVIDENCE: Therapeutic study, level IV.


Subject(s)
Brain Injuries/complications , Hemorrhage/chemically induced , Heparin, Low-Molecular-Weight/administration & dosage , Venous Thromboembolism/prevention & control , Adult , Aged , Anticoagulants/administration & dosage , Anticoagulants/adverse effects , Brain Injuries/diagnosis , Brain Injuries/therapy , Case-Control Studies , Female , Follow-Up Studies , Hemorrhage/epidemiology , Heparin, Low-Molecular-Weight/adverse effects , Hospital Mortality , Humans , Incidence , Injury Severity Score , Male , Middle Aged , Primary Prevention/methods , Reference Values , Retrospective Studies , Risk Assessment , Safety Management , Societies, Medical , Survival Analysis , Trauma Centers , Treatment Outcome , Venous Thromboembolism/epidemiology , Venous Thromboembolism/etiology , Wounds, Nonpenetrating/complications , Wounds, Nonpenetrating/diagnosis , Wounds, Nonpenetrating/therapy
9.
J Vasc Surg ; 52(5): 1135-9, 2010 Nov.
Article in English | MEDLINE | ID: mdl-20655690

ABSTRACT

OBJECTIVE: Current long-term surveillance after endovascular abdominal aortic aneurysm repair (EVAR) is based on high-resolution contrast-enhanced computed tomography (CT) scans at scheduled, lifelong intervals. The cancer and nephrotoxicity risks of interval CT scanning and prolonged radiation exposure are concerning. We sought to determine if surveillance CT angiography (CTA) can be safely reduced. METHODS: From July 2000 to November 2007, 345 patients were enrolled in U.S. Food and Drug Administration trials of the Powerlink System (Endologix, Irvine, Calif). An independent core laboratory analyzed 1519 post-EVAR CT scans (N=1519) to 5 years to evaluate aneurysm size, migration, presence of endoleak, and evidence of graft obstruction. Analyses were conducted to determine the value of the initial CTA scan in predicting future secondary procedures in enrolled patients. RESULTS: At any time during follow-up, CTA identified endoleak in 123 patients (36%), with 95% of endoleaks being type II. In addition, 49 patients underwent 72 secondary procedures at a mean of 22±21 months (range, 2-2007 days) after initial EVAR. These were based on clinical identification of limb ischemia in 13 interventions (18%) or core laboratory identification of abnormal CT finding in 58 interventions (81%). Of the 58 core laboratory identified findings, the inciting abnormality was present on the initial postoperative scan in 49 (84%). Of the remaining nine CT-driven procedures, three (5.2%) were due to late sac expansion attributed to type II endoleak (n=2) or endotension (n=1); two (3.4%) were for prophylactic reasons in the absence of endoleak; and four (6.8%) were in patients with type II endoleak not observed by the core laboratory and without sac expansion. The negative predictive value of the initial postoperative CTA for the need for a secondary procedure is therefore 96.4%, which can be improved to 97.6% with duplex ultrasound surveillance to detect sac expansion. Thus, a negative initial postoperative CTA is highly predictive of long-term freedom from secondary intervention. CONCLUSIONS: Among enrolled patients with suitable anatomy for EVAR, most abnormalities that result in a secondary procedure are detected on the initial postoperative CTA or present with clinical symptoms. Long-term surveillance CTA may therefore be replaced by duplex ultrasound imaging if the initial postoperative CTA shows no abnormalities.


Subject(s)
Aortic Aneurysm, Abdominal/diagnostic imaging , Aortic Aneurysm, Abdominal/surgery , Aortography/methods , Blood Vessel Prosthesis Implantation/instrumentation , Blood Vessel Prosthesis , Endovascular Procedures/instrumentation , Stents , Tomography, X-Ray Computed , Aged , Aged, 80 and over , Blood Vessel Prosthesis Implantation/adverse effects , Controlled Clinical Trials as Topic , Endoleak/diagnostic imaging , Endoleak/etiology , Endovascular Procedures/adverse effects , Female , Foreign-Body Migration/diagnostic imaging , Foreign-Body Migration/etiology , Graft Occlusion, Vascular/diagnostic imaging , Graft Occlusion, Vascular/etiology , Humans , Kaplan-Meier Estimate , Male , Multicenter Studies as Topic , Predictive Value of Tests , Prosthesis Design , Prosthesis Failure , Reoperation , Time Factors , Treatment Outcome , United States
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