Catheter-directed thrombolysis for severe pulmonary embolism in pediatric patients.

BACKGROUND: Catheter-directed thrombolytic (CDT) therapies for severe pulmonary embolism (PE) have been shown to be effective and safe when compared with systemic thrombolysis in adults. Pediatric studies assessing efficacy and safety of CDT for PE are lacking. Hence, our aim was to review CDT as a therapy for pediatric PE. METHODS: We retrospectively reviewed charts of patients aged <18 years, who underwent CDT for main or major branch pulmonary artery occlusion associated with hypotension or right ventricular dysfunction secondary to PE during a 3-year period, in our tertiary care academic Pediatric Intensive Care Unit. RESULTS: Six CDT interventions were performed on 5 patients with PE (median age: 16.5 years). All patients presented with chest pain and dyspnea. The predisposing factors for thrombogenesis differed in all patients, and all had multiple risk factors. Five of six procedures (83%) were accompanied by ultrasound agitation with EKOS endowave infusion system (ultrasound-accelerated CDT [UCDT]), whereas 1 had CDT without ultrasound agitation. Complete resolution of PE occurred in 4 instances (67%) at 24 hr, whereas in 2 cases (33%), there was partial resolution. One patient with complete resolution underwent another successful UCDT after 4 months for recurrence. Clinical parameters (heart rate, respiratory rate, blood pressure, and oxygen saturations) and echocardiographic findings improved after treatment in all the patients. Median duration of hospital stay was 9 days with no mortality and treatment-related complications. All patients were discharged with long-term anticoagulation. CONCLUSIONS: Our case series is the first that describes CDT/UCDT as an effective and safe therapy for pediatric patients with severe PE. CDT is known to accelerate fibrinolysis via focused delivery of thrombolytic agent to the thrombus site. For carefully selected patients, CDT/UCDT provides a useful treatment option for severe PE irrespective of the etiology, predisposing conditions, and associated comorbidities.

Evaluating effectiveness of antibiotic polymethylmethacrylate beads in achieving wound sterilization and graft preservation in patients with early and late vascular graft infections.

OBJECTIVE: The objective of the study was to evaluate the effectiveness of antibiotic-based polymethylmethacrylate (ab-PMMA) beads in achieving wound sterilization and graft preservation in patients with vascular graft infections. METHODS: We reviewed 31 patients treated for 37 graft infections over the past 5 years using ab-PMMA beads in a single institution. All patients were started on broad-spectrum antibiotics and later switched to targeted therapy based on intraoperative cultures for at least 6 weeks. All patients underwent multiple planned wound explorations, debridements and washouts. Cultures were obtained each time. Decision to do formal closure depended on culture results and wound appearance. All wounds were closed with a muscle flap. The endpoints included wound sterilization, limb salvage, recurrence of infection, and graft preservation. RESULTS: A total of 19 different organisms were cultured, and 48.6% of cases were polymicrobial, thereby accounting for a total of 60 isolates. The majority (n = 27) received a mix of tobramycin/vancomycin PMMA beads; vancomycin beads (n = 5); tobramycin beads (n = 1); and gentamicin/vancomycin beads (n = 4). Wound sterilization based on cultures was achieved in 32 of 34 wounds (94.1%). Of the cases, 5 underwent early graft removal, 3 with immediate reconstruction, and 1 case underwent a major amputation (2.7 %). Graft preservation was attempted in 32 cases (86.5%). No death occurred within 30 days. Limb salvage was achieved in 28 of the 32 preserved graft cases (87.5%) at a mean follow-up of 26 months (6 to 51 months). The long-term limb salvage rate for the cohort was 86.5%. Of the patients, 4 presented with recurrent graft infection and occlusion, causing acute limb ischemia and resulting in major amputation. The reinfection rate was 12.5% in the graft-preservation group and 11.4% in both the graft-preserved and the in situ replacement groups. CONCLUSION: Sterilization of graft infection can be achieved with ab-PMMA beads followed by closure with muscle flap, resulting in an acceptable limb-salvage rate despite virulent or polymicrobial graft infection.

Percutaneous profunda femoris artery revascularization to prevent hip disarticulation: case series and review of the literature.

BACKGROUND: Little is known about the role of percutaneous revascularization of the profunda femoral artery (PFA) in patients with amputation stump ischemia who are at risk of hip disarticulation. METHODS: We identified 4 patients who were treated for persistent amputation stump ischemia by PFA percutaneous revascularization over a 3-year period. All 4 patients had significant cardiopulmonary comorbidities and 2 patients had at least 3 previous groin surgeries. The short- and long-term outcomes of the patients were evaluated with regard to stump salvage, wound healing rate, complications, and mortality rate. RESULTS: Technical success was 100% with no procedure-related complications. All 4 patients had multilevel vascular disease involving the iliac, common femoral artery, and the profunda femoral artery. All 4 patients were treated with angioplasty and/or stenting of the PFA. The amputation stump was closed primarily in 3 patients and 1 amputation stump was closed with a skin graft. One patient died during the same hospital stay shortly after declining hemodialysis. Three patients are alive at a mean follow-up period of 9 months (range, 5-14 mo). CONCLUSIONS: Percutaneous PFA revascularization should be considered, over open revascularization, in patients with persistent above-knee amputation stump ischemia and multiple previous groin surgeries to avoid hip disarticulation.

Outcomes of laparoscopic ventral hernia repair with routine defect closure using "shoelacing" technique.

INTRODUCTION: Laparoscopic approach has become standard for many ventral hernia repairs. The benefits of minimal access include reduced wound complications, faster functional recovery, and improved cosmesis, among others. However, "bridging" of hernia defects during traditional laparoscopic ventral hernia repair (LVHR) often leads to seromas or bulging and, importantly, does not restore a functional abdominal wall. We have modified our approach to LVHR to routinely utilize transabdominal defect closure ("shoelacing" technique) prior to mesh placement. Herein, we aim to analyze outcomes of LVHR with shoelacing. METHODS: Consecutive patients undergoing LVHR with shoelacing were reviewed retrospectively. Main outcome measures included patient demographics, previous surgical history, intraoperative time, mesh type and size, postoperative complications, length of hospitalization, and hernia recurrence. RESULTS: Forty-seven consecutive patients underwent LVHR with defect closure. Average body mass index (BMI) was 32 kg/m2 (range 22-50 kg/m2). Eighteen (38%) patients had an average of 1.5 previous repairs (range 1-3). Mean defect size was 82 cm2 (range 16-300 cm2), requiring a median of 4 (range 2-7) transabdominal stitches for shoelacing. Two patients required endoscopic component separation to facilitate defect closure. Mean mesh size used was 279 cm2 (range 120-600 cm2). Mean operative time was 134 min (range 40-280 min). There were no intraoperative complications. Average length of hospitalization was 2.9 days (range 1-10 days). There were two major postoperative complications [one pulmonary embolism (PE), one stroke]; however, there was no wound-related morbidity or significant seromas. At mean follow-up of 16.2 months, there have been no recurrences. CONCLUSIONS: LVHR with defect closure confers a strong advantage in hernia repair, shifting the paradigm towards more physiologic abdominal wall reconstruction. In this series, we found our approach to be safe and comparable to historic controls. While providing reliable hernia repair, the addition of defect closure in our patients essentially eliminated postoperative seroma. We advocate routine use of the shoelace technique during laparoscopic ventral hernia repair.