Fluoroscopy-assisted dual-catheter thromboembolectomy: a new technique useful in patients with embolization to arteries of disproportionate diameters.

Distal embolization is a complication of aortoiliac aneurysm repair. Fluoroscopy-assisted catheter thromboembolectomy is useful in removing popliteal and tibial emboli from the femoral approach. Concomitant presence of aortoiliac and popliteal aneurysms, a known association, may present a difficult challenge to embolus extraction. Currently available embolectomy catheters large enough for thrombus extraction from a popliteal aneurysm are too large for safe tibial artery cannulation, and tibial balloon catheters cannot be enlarged sufficiently to transfer the thrombus through the aneurysmal popliteal segment. We treated a patient who embolized to his popliteal aneurysm and distal tibial circulation following aortoiliac aneurysm repair. A fluoroscopy-assisted dual-catheter technique was used to extract the thrombus through the femoral approach, eliminating the need for direct popliteal or tibial exploration. This technique uses two balloon catheters of graduated size, maneuvered concurrently under fluoroscopic guidance into the tibial and popliteal circulation. The smaller tibial catheter is inflated, and thrombus is withdrawn into the popliteal segment. The larger popliteal balloon catheter is then inflated distal to the smaller catheter, and both catheters are withdrawn simultaneously to deliver the clot through the femoral arteriotomy. This technique can be useful for successful balloon catheter extraction of thrombus via remote access, in an arterial system with variable diameter, eliminating the need for direct popliteal or tibial exploration.

Adrenal hemorrhage in a pediatric burn patient.

Adrenal hemorrhage with subsequent insufficiency is a rare complication in the burn patient. The case of a previously healthy 3-year-old Latin American male who was a victim of child abuse is presented. He suffered a submersion injury in hot water leading to a 45% total body surface area burn. An acute deterioration on the 7th post burn day was unresponsive to standard inotropic support and cardiopulmonary resuscitation. Post mortem examination revealed bilateral adrenal hemorrhage that had not been present 2 days earlier. To the authors' knowledge, this is the first reported case in a pediatric burn patient. The clinical manifestations of adrenal insufficiency vary widely and can be easily confused with sepsis. High index of suspicion is necessary for early diagnosis and treatment. Serum cortisol level should be checked and steroid therapy implemented if sepsis syndrome is unresponsive to standard therapy in this setting. This early intervention may be the key to improved survival of the burn patient with a sudden unexplained deterioration resistant to well established resuscitation methods.