Staged reconstruction of the inferior vena cava after gunshot injury.

A 23-year-old man with a gunshot injury to the abdomen and cardiac arrest requiring emergency department thoracotomy had a transection of the distal inferior vena cava (IVC) and small bowel injury. Because of persistent hemorrhagic shock, the IVC was ligated. During the next 3 days, he developed worsening bilateral leg edema. He was taken back for reanastomosis of his small bowel and reconstruction of the IVC using autologous femoral vein harvested from the right leg. We think that patients requiring ligation of the vena cava with worsening leg edema can benefit from a staged reconstruction of the IVC.

Tumescent anesthesia reduces pain associated with balloon angioplasty of hemodialysis fistulas.

We describe the use of tumescent local anesthesia during endovascular treatment of arteriovenous fistula stenosis. Using ultrasound guidance, 11 patients were hand-injected with tumescent lidocaine anesthesia around the fistula stenosis prior to endovascular therapy. All patients rated the pain experienced during angioplasty on a numeric scale (0-10). The mean balloon inflation pressure was 12 ± 3.01 atm. During angioplasty, eight patients reported pain between 0 and 2; three patients reported 4, 5, and 7 out of 10 on the pain scale. In this small series, tumescent anesthesia provided adequate pain control to perform angioplasty of arteriovenous fistulas.

Mediastinal approach to the placement of tunneled hemodialysis catheters in patients with central vein occlusion in an outpatient access center.

OBJECTIVES: Endovascular therapy for hemodialysis (HD) access is now performed in outpatient centers in a growing number of cities in the US. As patients live longer, we are facing a growing number of patients with central venous occlusion. We report our first three cases of mediastinal tunneled dialysis catheter placement in a clinic setting. METHODS: Between 15 November 2009 and 1 April 2010, three patients with central vein occlusion required tunneled HD catheter placement. Case #1 was a 60-year-old male with left subclavian and innominate vein occlusion from a defibrillator pacemaker and two previous right internal jugular tunneled dialysis catheters with occlusion of the right internal jugular vein. He lost right arm access after two failed arteriovenous fistulas (AVF) and an occluded upper arm AV graft. His last right external jugular catheter was removed for infection. Case #2 was a 72-year-old female with a thrombosed left upper arm and a right basilic vein AV access. She had a history of left leg deep vein thrombosis (DVT) and a vena cava filter. The left and right internal jugular veins were occluded as well as the left subclavian vein after stent placement. She required a tunneled HD catheter after a failed attempt at endovascular salvage of her right basilic AVF. Case #3 was a 78-year-old female who had been on HD for 4 yr. She refused AVF surgery and had four tunneled HD catheters removed for infection. She presented with bilateral internal jugular vein thrombosis and the removal of an infected right subclavian tunneled HD catheter. THE TECHNIQUE: The dialysis catheters were placed using standard C-arm fluoroscopy. We accessed the right femoral vein to pass a Berenstein catheter (Cordis, Inc, Warren, NJ) into the right innominate-subclavian vein junction. Using the catheter as a fluoroscopic target, a micropuncture needle was guided into the right innominate vein and a standard J-guidewire was used to dilate the mediastinal tract and place a new tunneled dialysis catheter. RESULTS: In all three cases, the tunneled dialysis catheters were placed under local anesthesia with no intravenous sedation. No pneumothorax occurred and all three catheters were used for HD within 24 hr. Two catheters were removed at 3 and 4 months for infection. One catheter continues to function well. CONCLUSIONS: As the lifespan of our dialysis patient population continues to improve, we will see an increasing need to perform complicated access procedures to maintain HD support. These three cases emphasize the value of the transmediastinal technique using basic C-arm fluoroscopy and a limited stock of basic catheters and guidewires.

In situ reconstruction with cryopreserved arterial allografts for management of mycotic aneurysms or aortic prosthetic graft infections: a multi-institutional experience.

We designed this study to evaluate a multi-institutional experience regarding the efficacy of cryopreserved aortic allografts in the treatment of infected aortic prosthetic grafts or mycotic aneurysms. We reviewed clinical data of all patients from 4 institutions who underwent in situ aortic reconstruction with cryopreserved allografts for either infected aortic prosthetic graft or mycotic aneurysms from during a 6-year period. Relevant clinical variables and treatment outcomes were analyzed. A total of 42 patients (37 men; overall mean age 63 +/- 13 years, range 41-74 years) were identified during this study period. Treatment indications included 34 primary aortic graft infections (81%), 6 mycotic aneurysms (22%), and 2 aortoenteric erosions (5%). Transabdominal and thoracoabdominal approaches were used in 38 (90%) and 4 patients (10%), respectively. Staphylococcus aureus was the most commonly identified organism (n=27, 64%). Although there was no intraoperative death, the 30-day operative mortality was 17% (n=7). There were 21 (50%) nonfatal complications, including local wound infection (n=8), lower-extremity deep venous thrombosis (n=5), amputation (n=6), and renal failure requiring hemodialysis (n=2). The average length of hospital stay was 16.4 +/- 7 days. During a mean follow-up period of 12.5 months, reoperation for allograft revision was necessary in 1 patient due to graft thrombosis (6%). The overall treatment mortality rate was 21% (n=9). In situ aortic reconstruction with cryopreserved allografts is an acceptable treatment method in patients with infected aortic prosthetic graft or mycotic aneurysms. Our study showed that mid-term graft-related complications such as reinfection or aneurysmal degeneration were uncommon.

Transthoracic cuffed hemodialysis catheters: a method for difficult hemodialysis access.

BACKGROUND: Recurrent vascular access failure is a major cause of morbidity in patients receiving long-term hemodialysis. Central venous catheters are often necessary for dialysis, and easily accessed vessels (ie, the internal jugular vein and subclavian vein) frequently occlude because of repeated cannulation. When standard access sites occlude, unconventional access methods become necessary. We report a technique of placing hemodialysis catheters directly into the superior vena cava (SVC). METHODS: Between January 2002 and December 2004, 22 patients with documented bilateral jugular and subclavian vein occlusion underwent transthoracic SVC permanent catheter placement. Femoral vein access was obtained, and a sheath was placed. Under fluoroscopic guidance, a diagnostic catheter was then inserted into the SVC, and a venogram was obtained. By using the fluoroscopic image as a reference guide, supraclavicular access directly into the SVC was performed with lateral and anteroposterior views to better localize the SVC. Once venous blood was obtained, a hydrophilic wire was passed into the inferior vena cava. A 5F sheath was then placed, and, with the use of an exchange catheter, the wire was switched for a stiffer wire. The hemodialysis catheter was then placed in the standard fashion over this wire. RESULTS: In a 24-month period, 22 patients underwent transthoracic permanent catheter placement. All patients had the permanent catheters successfully inserted. Two major complications occurred. One patient experienced a pneumothorax, and another patient experienced a hemothorax. Both patients were successfully treated with chest tube decompression. All permanent catheters functioned immediately with a range of 1 to 7 months. CONCLUSIONS: Transthoracic permanent catheter placement is an appropriate alternative for patients in whom traditional venous access sites are no longer available.

In situ reconstruction with cryopreserved arterial allograft in mycotic aneurysms or aortoiliac prosthetic grafts infection: a multi-institucional experience

Objective: Aortic prosthetic graft infection remains a highly fatal surgical complication. Recent studies with cryopreserved allografts inthe treatment of vascular graft infection suggest improved clinical outcomes. The purpose of this study was to evaluate the efficacy of cryopreserved aortic allografts in the treatment of infected prosthetic grafts or mycotic aneurysms. Methods: Clinical data of all patients who underwent in situ aortic reconstruction with cryopreserved allografts for either infected aortic prosthetic graft mycotic aneurysms from 1999 to 2003 were reviewed...

Real-time intravascular ultrasound-guided placement of a removable inferior vena cava filter.

BACKGROUND: Reports have demonstrated the benefit of prophylactic inferior vena cava filter (IVCF) placement to prevent pulmonary embolism. This series evaluates the potential for the bedside placement of a removable IVCF under "real-time" intravascular ultrasound (IVUS) guidance. METHODS: Twenty trauma patients underwent intensive care unit placement of a removable IVCF with IVUS guidance. All patients had ultrasonography of the femoral veins after placement to rule out postprocedure femoral vein thrombosis and radiographs to identify filter location. RESULTS: Nineteen of 20 IVCFs were placed at approximately the L2 level as verified by radiography. One patient had a large IVC (34 mm) and underwent bilateral common iliac IVCF placement under IVUS. Within 3 weeks of placement, 12 IVCFs were retrieved. Of the remaining eight patients, six had indications for permanent implantation, two had contralateral deep venous thrombosis, and one had ipsilateral deep venous thrombosis. CONCLUSION: Bedside insertion of a removable IVCF with IVUS guidance and its removal are simple, safe, and accurate.

Cellular remodeling of depopulated bovine ureter used as an arteriovenous graft in the canine model.

BACKGROUND: One of the greatest challenges in hemodialysis access surgery is improving the durability of prosthetic grafts caused by structural deterioration. The depopulated bovine ureter SynerGraft (SG) (CryoLife, Inc) is a tissue-engineered vascular graft processed to remove the xenograft cells while maintaining an unfixed connective tissue matrix capable of autologous cell repopulation by the recipient. STUDY DESIGN: Nineteen 6-mm diameter bovine ureter SG conduits were implanted in 12 dogs as arteriovenous grafts between the carotid artery and jugular vein (n = 11) or between the femoral artery and vein (n = 8). Performance of these biologic conduits was compared with that of 15 IMPRA (Bard) ePTFE grafts implanted in 9 dogs, including 9 arteriovenous grafts between the carotid artery and jugular vein and 6 femoral artery to femoral vein grafts. After 14 days, the grafts were accessed once weekly. Histologic and immunohistochemical analyses were performed on grafts explanted between 10 to 60 weeks. RESULTS: The 6- and 12-month primary patency rates of the bovine SG were 72.6% and 58.6%, respectively, compared with 6- and 12-month primary patency for ePTFE conduits of 57.4% and 57.4%, respectively. None of the bovine SG grafts became infected, but synthetic conduits became infected within 54 days of implantation. At 10 weeks, bovine ureter SG conduit showed fibroblast cell migration and proliferation with incorporation into the surrounding subcutaneous tissue, and elongated cells expressing the contractile protein smooth muscle actin were also observed. After 24 weeks, procollagen synthesis was demonstrated in the fully colonized graft matrix. The ePTFE grafts had no evidence of cellular ingrowth and an absence of endothelium. CONCLUSIONS: The bovine SG was appropriately remodeled to its host environment through an organized process of recellularization and neovascularization. The absence of infection, similar patency rates, and cell repopulation of the matrix warrant further investigation.

Bedside intravascular ultrasound-guided vena cava filter placement.

OBJECTIVE: Several reports have demonstrated the efficacy of inferior vena cava filter (IVCF) placement with intravascular ultrasound guidance (IVUS). The majority of these procedures,however, have been done in concert with contrast venography and/or fluoroscopic guidance. The purpose of this report was to evaluate the potential for bedside IVCF placement with "real-time" IVUS guidance only. DESIGN OF STUDY: In a phase I trial, 10 patients underwent IVUS interrogation of the IVC for diameter measurements and localization of the renal veins. Contrast venography verified the IVUS findings prior to filter deployment. In a phase II trial, another 35 patients underwent intensive care unit bedside placement of an IVC filter with only "real time" IVUS guidance using a double puncture technique in the same femoral vein. All patients underwent color-flow ultrasonography of the femoral veins after filter placement to rule out post procedure femoral vein thrombosis and plain radiographs of the abdomen to identify filter location. RESULTS: In the phase I trial, all filters were placed within 15 mm of the most inferior renal vein identified by IVUS. There were no complications, and successful filter placement was verified by contrast venography. In phase II, 33 IVCFs were placed without complications at approximately the L2 level by plain radiograph. One patient had an IVCF deployed in the common iliac vein, which necessitated placement of an uneventful second IVCF at the infrarenal location by IVUS. This same patient had a femoral deep venous thrombosis identified by postoperative duplex ultrasonography. A second patient had IVC thrombus identified by IVUS, and placement was performed with contrast venography in the fluoroscopy suite. IVC measurements ranged from 18-28 mm in diameter. CONCLUSIONS: IVUS accurately measures the IVC diameter and localizes the renal veins, allowing for exact placement of IVCFs. IVUS further avoids the need for contrast agents and for transport of critically ill patients. Bedside insertion of an IVcF with IVUS guidance is simple, safe, and accurate. Further assessment of this technique is warranted.

Remote superficial femoral artery endarterectomy and distal vein bypass for limb salvage: initial experience.

PURPOSE: To examine the results of remote superficial femoral artery endarterectomy (RSFAE) performed through a small groin incision in conjunction with distal saphenous vein (SV) bypass for limb salvage. METHODS: A retrospective study was conducted of 21 patients (14 men; mean age 68.5 years, range 47-78) who underwent RSFAE and distal SV bypass between May 1998 and September 2001 for limb salvage. Thirteen had gangrene and 8 had rest pain. RSFAE was performed with the MollRing Cutter device through a femoral arteriotomy; the distal atheromatous plaque was "tacked up" with a stent. Distal SV bypass from the proximal popliteal artery was performed in situ in 7, from a transposed harvested vein in 8, or from a reversed graft in 6. All patients underwent follow-up examination with serial color-flow ultrasound scans. RESULTS: The mean length of the endarterectomized SFA was 26.5 cm (range 12-40). There were no deaths, only 2 wound complications, and the mean hospital length of stay was 3.1+/-0.6 days. The primary cumulative patency rate by life-table analysis was 71.4% with follow-up extending to an average of 12.4 months (range 1-18). There were 2 amputations for gangrene and 6 percutaneous procedures in 4 (19.1%) patients to maintain bypass patency, producing an assisted primary patency rate of 81.5%. The locations of the restenoses were evenly distributed along the endarterectomized SFA and SV graft. CONCLUSIONS: When adequate SV is not available, RSFAE with residual SV bypass is a safe and moderately durable procedure that may prove to be a useful adjunct for limb salvage, especially in the presence of foot infection, where an autogenous tissue bypass is preferred.

Intraaortic stabilization of the AneuRx stent-graft system: a useful adjunct to minimize device migration.

The deployment of a Medtronic AneuRx stent-graft system for endovascular abdominal aortic aneurysm repair requires a series of precise maneuvers that include positioning the primary delivery catheter in the infrarenal aorta, retracting the graft-covering sheath, and withdrawing the stainless steel runners. The last step allows the stent-graft to fully expand and attach to the non-aneurysmal aorta and iliac arteries. Such maneuvers may cause the stent-graft to move caudally if the device is placed in a severely angulated aortic neck. We describe a simple, coaxial, stabilization technique utilizing the contralateral introducer sheath which minimizes potential caudal migration of the stent-graft in angulated aortic necks during runner withdrawal.

Topical application of beta-radiation to reduce intimal hyperplasia after carotid artery balloon injury in rabbit. A possible application for brachytherapy in vascular surgery.

PURPOSE: Endovascular brachytherapy for the prevention of intimal hyperplasia (IH) and restenosis after balloon/stent angioplasty has proven effective both in animal preparations and clinical trials. A variety of beta-emitting isotopes and catheter-based devices have been developed for the delivery of low-dose radiation in clinical coronary and peripheral trials. No platform, however, has yet been developed for brachytherapy in concert with vascular surgical operations. The purpose of this study was to evaluate the vascular histopathologic response following balloon injury to rabbit carotid arteries with and without topically applied low-dose beta-radiation. METHODS: The beta-emitting isotope strontium-90 (Sr-90) was conjugated onto the matrix of polypropylene (PLYP) mesh. Rabbit carotid arteries were balloon-injured with a #2 embolectomy catheter. Six carotid arteries were wrapped with nonradioactive PLYP mesh (controls) and Sr-90 ( approximately 90 microCi) PLYP mesh in order to deliver low-dose radiation to the vessel wall from the external (adventitial) surface. Tissue was harvested at 6 weeks and processed for histologic examination. RESULTS: There was consistent blockade of fibrocellular neointima formation with virtually no neointima present in all treated segments, compared to moderate neointima formation in controls. Medial thinning and smooth muscle cell (SMC) necrosis were also associated with topical brachytherapy. CONCLUSION: beta-Radiation applied by an externally wrapped PLYP mesh labeled with Sr-90 markedly suppressed neointima formation in an animal vascular surgical injury model. Further studies, however, are necessary to determine a suitable isotope and dosage for clinical application.

Hemodialysis graft infections treated with cryopreserved femoral vein.

Introduction. Treatment of infected hemodialysis grafts is associated with prolonged hospitalization and wound care. The use of cryopreserved femoral vein (CFV) for angioaccess in infected hemodialysis grafts was prospectively evaluated.Methods. Forty-three CFV arteriovenous grafts (AVGs) were placed in 43 patients with prosthetic AVG infections. Thirty-two of the CFV AVGs were constructed adjacent to the infected AVG using a parallel tunnel tract, while 11 were placed into the infected field. All patients were prospectively followed at three-month intervals for graft complications and recurrent infections.Results. With a mean follow-up of 418 days, there was one recurrent infection (2.3%). The one-year primary and secondary graft patency rates were 42% and 68%, respectively. The two-year primary and secondary patency rates were 31% and 63%, respectively.Conclusions. Cryopreserved femoral vein proved useful in the treatment of infected hemodialysis grafts. The absence of infection after implantation around an infected area shows promise for salvaging an angioaccess site that would otherwise have been abandoned.