The Utility of Postoperative Bracing on Radiographic and Clinical Outcomes Following Cervical Spine Surgery: A Systematic Review.

STUDY DESIGN: Systematic Review. OBJECTIVES: To determine the radiographic and clinical utility of postoperative orthoses following cervical spine surgery. METHODS: We performed a search of the PubMed, Cochrane Library, Medline Ovid, and SCOPUS databases from inception until November 2021. Eligible studies included outcomes of postoperative bracing vs no bracing following cervical spine surgery. The primary outcome of interest was fusion rates after cervical surgery in braced vs unbraced patients. Secondary outcomes included patient reported outcomes and complication rates. RESULTS: A total of 3232 titles were initially screened. After inclusion criteria were applied, 7 studies (550 patients) were included, which compared results of braced vs unbraced patients after cervical spine surgery. These studies showed acceptable reliability for inclusion based on the Methodical Index for Non-Randomized studies and Critical Appraisal Skills Programme assessment tools. There were no significant differences in fusion rates or complications between braced vs unbraced patients identified in any study. Patient reported pain and quality of life measures between braced and unbraced groups varied amongst studies, without any clear overall advantages favoring either method. CONCLUSIONS: This systematic review found that external bracing, though widely used following cervical spine surgery, may not offer any advantages in patient-reported outcomes, as compared to not bracing. In regard to the effect of bracing on fusion rates, no strong consensus can be made as the methods of fusion assessment in the included studies were heterogenous and suboptimal. Future high-quality studies using recommended methods of fusion assessment are needed to adequately address this important question.

Delayed Traumatic Aortic Pseudoaneurysm Formation Causing Vertebral Body Erosion and Back Pain: Case Report and Literature Review.

BACKGROUND: Aortic pseudoaneurysms are a rare cause of chronic back pain, usually resulting from compression of the adjacent neurovasculature. It is uncommon for patients with pseudoaneurysms of the abdominal aorta to present in a delayed fashion after initial traumatic injury. CASE DESCRIPTION: We describe an unusual case of delayed pseudoaneurysm formation with subsequent erosion into the adjacent L1 vertebral body. This pseudoaneurysm was secondary to a gunshot wound with retained ballistic fragment that had occurred 27 years previously. Herein, we discuss the patient's presenting symptoms, imaging, and overall treatment. In this particular case, we used a combined surgical and endovascular (hybrid) approach after the patient experienced recurrent low back pain, weeks after a primary endovascular treatment was performed. We additionally review the current literature on the management of aortic pseudoaneurysms causing vertebral body erosion and back pain. CONCLUSIONS: In our patient, a combined surgical and endovascular (hybrid) approach led to the complete resolution of his back pain symptoms and to complete exclusion of the pseudoaneurysm on follow-up imaging. Endovascular management of aortic pseudoaneurysms may be a reasonable alternative to open surgery in high-risk patients; however, this approach may result in a higher recurrence of pseudoaneurysm and initial presenting symptoms. Further investigation is needed to elucidate the efficacy of endovascular treatment of these lesions.

Needle loss in subclavian vein during central venous catheter placement: case report of a rare complication.

We present a case of needle separation during central venous catheter (CVC) placement in a super morbidly obese patient with subsequent surgical intervention in its retrieval. This complication, potentially lethal due to the relevant anatomy of such a procedure, alerts critical care physicians and surgeons to the possibility of equipment failure and stresses proper technique in what has become a routine procedure. It also emphasizes the routine use of ultrasound-guidance for cannulation in patients of any body habitus. While infection and arrhythmia are the generally known complications of CVC placement, clinicians must be alert to unanticipated events such as needle separation. In our case, the retrieval of this needle required multi-disciplinary intervention between radiology, critical care, vascular surgery, and thoracic surgery. Our event stresses hypervigilance to complications in a common procedure.

A comparison of tibial artery bypass performed with heparin-bonded expanded polytetrafluoroethylene and great saphenous vein to treat critical limb ischemia.

BACKGROUND: Expanded polytetrafluoroethylene (ePTFE) bonded with heparin (HePTFE) has been reported to perform equivalent to saphenous vein graft (SVG) for below-knee bypass. This series examines outcomes for tibial artery bypass using HePTFE and SVG over a contemporaneous time period. METHODS: A retrospective analysis of prospectively collected data was conducted for 112 tibial bypasses (62 HePTFE, 50 SVG) performed from November 2006 to January 2009. Demographics for age, sex, race, diabetes mellitus, and end-stage renal disease were similar. Indications for revascularization were also similar: disabling claudication, 9%; rest pain, 25%; and tissue loss, 66%. The HePTFE group included more reoperative procedures (45% vs 26%). All HePTFE bypasses were performed using an autologous vein patch at the distal anastomosis. Postoperative graft surveillance by pulse examination, ankle-brachial index, and duplex ultrasound imaging occurred at 1, 3, 6, and 12 months. Follow-up ranged from 1 to 12 months. Kaplan-Meier and Cox regression analysis evaluated results in patients with no missing variables. RESULTS: HePTFE and SVG bypasses demonstrated no significant differences in target tibial artery distribution: anterior tibial (15 vs 17), dorsalis pedis (4 vs 5), posterior tibial (22 vs 16), and peroneal (21 vs 12). Graft occlusion occurred in 19 patients (16.9%) during follow-up. Primary patency at 1 year was 75.4% for HePTFE and 86.0% for SVG. There was no significant difference in primary patency due to sex (male, 78%; female, 84%), race (white, 82%; African American, 77%), or diabetes mellitus (no diabetes mellitus, 84%; diabetes mellitus, 76%). End-stage renal disease resulted in decreased patency (57%), with an eightfold reduction (95% confidence interval, 1.8%-39.8%; P = .006). SVG patients had a lower risk of occlusion/death (95% confidence interval, 14.2%-94.5%; P > .05). Sixteen amputations were performed, with no significant difference based on conduit. CONCLUSIONS: This experience indicates a trend for single-segment quality saphenous vein to remain the conduit of choice for tibial artery bypass compared with HePTFE. Factors relevant to decreased 1-year patency for the entire cohort were end-stage renal disease and nonhealing ulceration as the indication for revascularization. Although relatively short-term, these results do support HePTFE as a viable alternative conduit for patients with absent or poor quality saphenous vein who need a tibial bypass.

Perforation complicating carotid artery stenting: the use of a covered stent.

Carotid artery angioplasty and stenting has emerged as an effective strategy for the treatment of significant carotid artery stenosis. Perforation during carotid artery stenting is a very rare potential complication of the procedure. We describe a case of carotid artery perforation that occurred during postdilation of the carotid artery stent. In our case this potentially serious complication was successfully treated with a covered stent-graft.

Renal artery stenting using gadodiamide arteriography in patients with baseline renal insufficiency.

PURPOSE: To investigate whether a contrast agent containing gadodiamide can reduce the incidence of contrast-induced nephropathy associated with renal artery stenting in patients with preexisting renal insufficiency. METHODS: Between 1999 and 2002, gadodiamide-based arteriography was used in 20 patients (12 men; mean age 69 years) with significant baseline renal insufficiency (creatinine > or =1.7 mg/dL) undergoing renal artery stenting for > or =70% stenoses in 25 renal arteries. Baseline creatinine levels were compared to postprocedure and midterm follow-up levels. RESULTS: Procedural success was 100%. An average of 74 mL of gadodiamide contrast was used per case. Four patients received an additional 30 mL (mean) of iodinated contrast due to poor image quality with gadodiamide alone. There was no significant change in mean creatinine levels at discharge (2.9 mg/dL) compared to baseline (3.0 mg/dL, p=0.72). At midterm follow-up, mean creatinine levels (2.4 mg/dL) were significantly lower compared to baseline (p=0.004). CONCLUSIONS: Gadodiamide-based arteriography can be effectively used during RAS in patients with baseline renal insufficiency. This technique may enhance the renal-protective effect of renal artery stenting in this high-risk population with renal artery stenosis.