Manual compression versus MANTA device for access management after impella removal on the ICU.

To compare the safety and efficacy of manual compression versus use of the MANTA closure device for access management after Impella removal on the intensive care unit (ICU). The number of patients treated with percutaneous left ventricular assist devices (pLVAD), namely Impella and ECMO, for complex cardiac procedures or shock, is growing. However, removal of pLVAD and large bore arteriotomy closure among such patients on the ICU remains challenging, since it is associated with a high risk for bleeding and vascular complications. Patients included in a prospective registry between 2017 and 2020 were analyzed. Bleeding and vascular access site complications were assessed and adjudicated according to VARC-2 criteria. We analyzed a cohort of 87 consecutive patients, who underwent access closure after Impella removal on ICU by using either the MANTA device or manual compression. The cohort´s mean age was 66.1 ± 10.7 years and 76 patients (87%) were recovering from CS. Mean support time was 40 h (interquartile range 24-69 h). MANTA was used in 31 patients (35.6%) and manual compression was applied in 56 patients (64.4%). Overall access related bleedings were significantly lower in the MANTA group (6.5% versus 39.3% (odds ratio (OR) 0.10, 95% CI 0.01-0.50; p = 0.001), and there was no significant difference in vascular complications between the two groups (p = 0.55). Our data suggests that the application of the MANTA device directly on the ICU is safe. In addition, it seems to reduce access related bleeding without increasing the risk of vascular complications.

Coil embolization of a thoracic aorta hematoma with branch artery pseudoaneurysm - case report.

BACKGROUND: A thoracic aorta hematoma with branch artery pseudonaneurysm is a very rare complication of thoraric blunt trauma. The standard treatment of this type of injury is aortic endograft placement. CASE PRESENTATION: We present a case in which a thoracic aorta hematoma with branch artery pseudoaneurysm was treated with coil embolization instead of endografting. CONCLUSIONS: Coil embolization of aortic injuries may be a safe and definitive treatment alternative in selected cases. This technique has the potential to reduce the risk of procedure-related complications.

Insights From a Multidisciplinary Introduction of the MANTA Vascular Closure Device.

OBJECTIVES: The aim of this paper is to report insights from the first 100 consecutive cardiovascular procedures with MANTA closure. BACKGROUND: The collagen-based MANTA vascular closure device (Teleflex, Wayne, Pennsylvania) has recently been approved for the closure of large-bore femoral access. METHODS: Procedural and access site-related complications were analyzed according to Valve Academic Research Consortium-2 criteria. Duration of bleeding after device closure was recorded. RESULTS: Patients underwent transcatheter aortic valve replacement (n = 75), endovascular aortic replacement (n = 21), or Impella left ventricular support (n = 4). In these 100 patients, a total of 122 MANTA devices were used (22 patients had bilateral large-bore access). None of the patients received protamine. Immediate hemostasis was achieved in 70 patients and hemostasis within 5 min in 87 patients. There were 7 patients with major and 4 patients with minor MANTA-associated vascular complications: femoral artery occlusion in 2, ongoing bleeding in 5, and pseudoaneurysm formation in 4 patients. One patient was treated with covered stent implantation, 7 required surgical revision, and 4 received thrombin injection. Complications occurred significantly more often in patients with peripheral artery disease and a minimal artery diameter <6 mm. Careful review of these complications suggests 3 distinct failure mechanisms. In vessels with narrow femoral artery diameters, elevation of the toggle may lead to occlusion of the artery, incomplete apposition of the plug may lead to perivascular (potentially retroperitoneal) bleeding, or pseudoaneurysm formation may occur. CONCLUSIONS: In this paper, MANTA-associated complications are addressed, 3 distinct failure mechanisms are suggested, and strategies to avoid these complications and improve procedural outcomes are discussed.

Endovascular aortic sealing with Nellix reduces intraoperative radiation dose when compared to endovascular aortic repair.

OBJECTIVE: To analyze radiation exposure during endovascular aortic sealing (EVAS) in comparison with standard endovascular aortic repair (EVAR) in clinical practice. METHODS: From December 2013 to October 2016 (35 months), 60 patients were analyzed for intraoperative radiation exposure during EVAR: 30 consecutive patients (mean age, 73.10 years; 28 male) received EVAS (Nellix Endologix); within the same time frame, 30 patients were treated with standard EVAR (mean age, 71.87 years; 30 male). An indirect dose analysis was performed for both groups of patients, including effective dose and cumulative air kerma. Furthermore, fluoroscopy time (FT), dose area product, and time of procedure were included in the study. RESULTS: The effective dose was significantly reduced in the EVAS group (3.72 mSv) compared with the group treated with standard EVAR (6.8 mSv; P ≤ .001). The cumulative air kerma was also lowered in EVAS (67.65 mGy vs 139 mGy in EVAR; P ≤ .001). FT for the entire group was 13 minutes and was shorter (P < .001) for EVAS (9 minutes) in comparison with EVAR (19 minutes). The dose area product for the entire cohort was 16.95 Gy.cm2 and was lower during EVAS (12.4 Gy.cm2) than during EVAR (22.6 Gy.cm2; P < .001). The median operating time for the entire group was 123.5 minutes and was significantly shorter (P < .01) for EVAS (119 minutes vs EVAR at 132 minutes). The FT shows a significant correlation with the patient's weight (P = .022), body mass index (P = .004), and time of procedure (P = .005). CONCLUSIONS: EVAS is associated with a relevant decrease in indirect measured radiation dose and time of procedure compared with standard EVAR. A relevant reduction in dose during EVAS is highly likely to result in lower exposure to radiation for physicians and staff. Such a result would be highly advantageous and calls for further analysis.

Acute Venous Iliofemoral Thrombosis: Early Surgical Thrombectomy Is Effective and Durable.

BACKGROUND: The first-line recommendation for the treatment of acute iliofemoral deep vein thrombosis (IFDVT) is catheter-directed thrombolysis or pharmacomechanical thrombolysis. Recent analysis of surgical thrombectomy has shown comparable results. However, this procedure is not commonly given as much importance as interventional techniques. We analyzed the patient outcome of surgical thrombectomy using modern endovascular techniques in both the short and long term. METHODS: All consecutive patients who underwent surgical thrombectomy at our institution between April 2008 and April 2017 were included. Only patients with iliofemoral thrombosis, and only those with the first onset of symptoms <10 days, were analyzed. All patients received preoperative duplex ultrasound and contrast-enhanced computed tomography scans for thrombus extension and detection of pulmonary embolism. All operations were performed by vascular surgeons with open and endovascular skills in a C-arm-equipped operating room. During follow-up (FU), all patients received clinical examination for symptoms of postthrombotic syndrome (PTS), as well as duplex ultrasound. RESULTS: Within a 9-year period, 21 patients underwent surgical thrombectomy for IFDVT (17 females/4 males). Primary technical success was 100%; 10 (47.6%) patients received additional primary stenting. 30-day mortality was 0%, 3 patients (14.3%) needed reoperation for early rethrombosis, while secondary 30-day patency was 100%. During FU (median, 6 years; range, 1-104 months), 1 patient received additional stenting for stenosis of the common iliac vein. Nineteen patients (90.5%) presented patent iliofemoral veins without signs of rethrombosis. Two patients (9.5%) died during FU of cancer without signs for recurrent IFDVT. All patients with patent veins were free of symptoms for PTS. CONCLUSIONS: Surgical thrombectomy for acute IFDVT is a successful, safe, and durable procedure and provides alternative treatment options for acute IFDVT in selected cases.

Ultrasound-guided carotid sheath block for carotid endarterectomy: a case series of the spread of injectate.

INTRODUCTION: We aimed to show the spread of local anesthetic following an ultrasound-guided, double-injection technique of a carotid sheath block before carotid endarterectomy. METHODS: The study included 15 patients scheduled for elective carotid endarterectomy. The carotid sheath block was performed after ultrasound-guided localization of the carotid bifurcation (level C4-C6) at the posterior border of the sternocleidomastoid muscle. A mix of 7.5 mL ropivacaine 0.75%, 7.5 mL prilocaine1% and 3 mL iopromidum was injected at the base of the carotid bifurcation. An additional 15 mL of the mixture was administered subcutaneously at the surgical incision line. Thirty minutes after the block, a computed tomography scan of the head, neck region and upper thorax was performed to reconstruct a 3-D distribution of the injectate. RESULTS: All patients achieved C2-C4 dermatomal sensory blockade. None required conversion to general anesthesia. The injectate spread ranged from the vertebral body of C1 to the vertebral body of T3. The mean volume of distribution was 97±13 mL, the craniocaudal spread 138±19 mm, dorsoventral 57±8 mm and coronal 53±8 mm. The mean carotid artery circumference contact was 252°±77, with four patients (27%) presenting with a ring formation (360°) around the carotid artery. CONCLUSIONS: Ultrasound-guided carotid sheath block provided an extensive spread of local anesthetic. A complete ring formation of local anesthetic around the artery does not seem necessary for a successful anesthesia. The resulting nerve blockade thus appears sufficient for surgery, with minor risks compared to blind methods.

Impact of an intensive 2-day endovascular training course on technical performance of trainees.

BACKGROUND: The objective of this study was to evaluate the effect of a 2-day international endovascular training course on the performance of trainees as compared with a control group, assessed in a bench model-based task using an objective structured evaluation protocol. METHODS: A total of 50 trainees, 28 course participants of 2 consecutive identical courses and a control group of 22 participants with a similar level of experience without course attendance, underwent baseline and final assessment (simulated arterial access task). The evaluation form consisted of a global assessment (GA), task-specific checklist percentage score (CL), and global rating scale percentage score (GR), with both percentage scores ranging from 0% (worst performance) to 100% (best performance). RESULTS: Course participants were more likely to pass the GA at final testing than the control group (odds ratio=59; 95% confidence interval [CI] 9.5-656; P<0.001). The estimated difference in percentage score at final testing between course participants and the control group was 26% (95% CI 18-34; P<0.001) for the CL and 29% (95% CI 19-40; P<0.001) for the GR. CONCLUSIONS: A 2-day structured endovascular training course significantly improves endovascular performance in a simulated environment. These results are important for the design of endovascular training curricula with the ultimate goal of contributing to patient safety.

Deviation from Murray's law is associated with a higher degree of calcification in coronary bifurcations.

OBJECTIVE: Murray's law describes the optimal branching anatomy of vascular bifurcations. If Murray's law is obeyed, shear stress is constant over the bifurcation. Associations between Murray's law and intravascular ultrasound (IVUS) assessed plaque composition near coronary bifurcations have not been investigated previously. METHODS: In 253 patients plaque components (fibrous, fibro-fatty, necrotic core, and dense calcium) were identified by IVUS in segments proximal and distal to the bifurcation of a coronary side branch. The ratio of mother to daughter vessels was calculated according to Murray's law (Murray ratio) with a high Murray ratio indicating low shear stress. Analysis of variance was used to detect independent associations of Murray ratio and plaque composition. RESULTS: Patients with a high Murray ratio exhibited a higher relative amount of dense calcium and a lower amount of fibrous and fibro-fatty tissue than those with a low Murray ratio. After adjustment for age, sex, cardiovascular risk factors or concomitant medications, the Murray ratio remained significantly associated with fibrous volume distal (F-ratio 4.90, P=0.028) to the bifurcation, fibro-fatty volume distal (F-ratio 4.76, P=0.030) to the bifurcation, and dense calcium volume proximal (F-ratio 5.93, P=0.016) and distal (F-ratio 5.16, P=0.024) to the bifurcation. CONCLUSION: This study shows that deviation from Murray's law is associated with a high degree of calcification near coronary bifurcations. Individual deviations from Murray's law may explain why some patients are prone to plaque formation near vessel bifurcations.

[Case Report: complication after surgical discectomy]. / Kasuistik interaktiv: Komplikation nach lumbaler Bandscheibenoperation.

Lesions to retroperitoneal blood vessels are rare but serious complications of surgical discectomies. Through ventral perforation during laminectomy life-threatening bleedings may occur if arteries are injured. We present a patient with haemorrhagic shock after disc surgery. The complication could be treated adequately by immediate anaesthesiological and surgical intervention and the patient recovered completely.

Long-term outcome of operated inflammatory aortic aneurysms.

Inflammatory aortic aneurysms (IAAs) represent a rare form of aortic aneurysms. Compared with atherosclerotic aneurysms, patients with IAA have an increased risk of perioperative and long-term morbidity. This retrospective clinical study analyzed the outcome after conventional and endovascular repair of IAAs. Patients treated for an abdominal IAA between January 1995 and November 2004 were included. Imaging (computed tomographic angiography or magnetic resonance angiography) was performed preoperatively and at the time of follow-up (mean 2.7 years). Transperitoneal open repair and endovascular aortic repair were the operative procedures used. Over 10 years, 40 patients were treated with conventional and 5 patients with endovascular repair. The in-hospital morbidity rate was 11.1% (five patients; four conventional, one endovascular). On 10 patients (47.6%), the retroperitoneal fibrosis was no longer detectable. After operative repair, the majority of cases presented with a distinct regression of inflammation. Endovascular treatment of IAA represents a feasible alternative procedure to open aortic repair.

Early surgical outcome after failed primary stenting for lower limb occlusive disease.

PURPOSE: To evaluate the early results of revascularization after failed primary stent placement for lower limb occlusive disease. METHODS: A retrospective review was conducted of 25 consecutive patients (16 men; mean age 65 years, range 32-89) treated between January 2001 to October 2003 for infrainguinal stent failure at a median 6.6 months (range 3-60) after primary stent implantation (27 femoropopliteal and 20 popliteal-crural) at referring hospitals. All surgical procedures for stent failure were performed at tertiary centers. The results of bypass grafting for failed stenting were compared to a contemporaneous cohort of patients undergoing primary bypass surgery performed by the same surgeons. RESULTS: At the time of admission, 22 stents were thrombosed, and 3 patent stents presented with >50% in-stent stenosis. Twenty patients had 7 femoropopliteal or 9 femorodistal vein bypasses and 4 reconstructions of the common femoral or profunda femoris artery. Four patients had 3 primary amputations and 1 lumbar sympathectomy. One patient with claudication was treated conservatively. Procedure-related complications were observed in 40%; 30-day mortality was 4% (1/25). Early (30-day) graft thrombosis occurred in 6 (30%) of 20 arterial reconstructions, necessitating 8 secondary amputations (44% [11/ 25] overall amputation rate). A total of 47 surgical procedures were performed in the 24 surviving patients (median 2 operations per patient, range 1-9) over an 11-month period (range 1-57). Primary patency rates at 30 days and at 6 and 12 months were 67%, 44%, and 33%, respectively, in the poststent bypass cohort versus 98%, 96%, and 88%, respectively, in a contemporaneous group of patients treated with primary bypass grafting. CONCLUSIONS: Failed stents in lower limb arteries often require distal reconstructive bypass surgery, which is associated with high complication rates and poor outcome, including major amputations. There is no scientific evidence to support stenting below the inguinal ligament.