Treatment of postcatheterisation false aneurysms: ultrasound-guided compression vs ultrasound-guided thrombin injection.

OBJECTIVES: to compare the efficacy and cost-effectiveness of ultrasound-guided compression (UGC) with ultrasound-guided thrombin injection (UGTI) for treatment of postcatheterisation arterial false aneurysms (cFA). DESIGN: prospective clinical study using historical controls. MATERIALS AND METHODS: we prospectively collected data on 33 consecutive patients diagnosed with cFA larger than 1.5 cm in diameter. These were treated with UGTI. We performed a retrospective review of data on a former group of 33 consecutive historical control patients that were treated by UGC. RESULTS: the groups were similar in respect of demographic and clinical variables. Thirty patients were suitable for UGC and 33 patients were suitable for UGTI. The success rate for UGC was 26/30 (87%) compared to 33/33 (100%) for UGTI (p<0.05). Thrombosis was achieved during the first treatment session in 7/26 patients treated by UGC, compared to 26/33 in the UGTI group (p<0.0001). Four patients that failed UGC and two patients that were unsuitable for UGC required surgical repair. UGTI as compared to UGC was shorter in duration (25 vs 75 min) and required no sedation. No thromboembolic or systemic complications occurred in either group. Cost analysis revealed savings of $US 517 for each patient treated by UGTI as compared with UGC. CONCLUSIONS: in our study, UGTI is superior to UGC, and we suggest that UGTI should become the procedure of choice for the treatment of cFA.

Thromboembolic complications of central venous catheterization of the arm and neck veins.

For more than 30 years central venous catheterization has provided an important means of long-term vascular access and circulatory monitoring. Thrombosis of central veins is one of the serious complications of this procedure, The reported incidence of thrombosis varies and it is often underestimated clinicaIly due to the pau city of signs and symptoms. Symptomatic subelavian vein thrombosis is estimated to occur in up to 15% of patients with indwelling venous access devices.

Lateral venous ulcer and short saphenous vein insufficiency.

PURPOSE: The objective of this report is to emphasize the importance of saphenopopliteal junction (SPJ) reflux in the genesis of lateral leg ulcers and to suggest a proper diagnostic and therapeutic approach. METHODS: Twenty legs with isolated lateral perimalleolar ulcers from the basis for this report. None had medial ankle ulcers, and most showed no hyperpigmentation or lipodermatosclerosis. Fifteen had been treated with a nonvenous diagnosis. Reflux at the SPJ was detected by handheld continuous wave Doppler and was confirmed with duplex scans. No other abnormalities were found. Brief conservative treatment and duplex localization of the SPJ preceded its ligation and division. RESULTS: All ulcers healed within 12 weeks, but one in a radiated leg recurred at 9 months. Other complications included two hematomas and one each of ankle edema, superficial wound infection, and sural neuropathy. CONCLUSIONS: Even isolated lateral leg and ankle ulcers with minimal accessory venous stigmata can be of venous reflux origin. Detection with the continuous wave Doppler and confirmation of reflux and localization of the SPJ allow surgical correction to proceed swiftly with an expectation of satisfactory results.

Intraoperative urokinase as an alternative to heparin for patients with suspected heparin-induced thrombocytopenia requiring arterial reconstruction: report of a case and review of the literature.

Patients with heparin-induced thrombocytopenia (HIT) require an alternative antithrombotic treatment to heparin during arterial reconstruction. Ancrod and Iloprost have been employed but are not readily available and carry the risks of systemic side effects (depletion of fibrinogen, hypotension). A patient with HIT in whom intraoperative intraarterial urokinase (UK) was successfully utilized to enable safe arterial reconstruction is described. An 80 year old white female with diffuse arteriosclerotic cardiovascular disease and multiple vascular reconstructions had thrombotic complications following use for heparin during two of her prior operations associated with documented thrombocytopenia and anti-platelet antibodies. She presented with limb-threatening ischemia which was evaluated with angiography revealing severe stenosis of the proximal left superficial femoral artery, occlusion of both anterior tibial and peroneal arteries and several digital vessels, with intact posterior tibial runoff. A common femoral to mid-superficial femoral artery bypass was performed, utilizing contralateral reversed greater saphenous vein, while being treated with aspirin and a continuous intravenous infusion of low molecular weight dextran. During the procedure the clamped arteries were locally perfused with a high volume of dilute UK solution to prevent blood stasis, and enable local delivery of a thrombolytic agent. Although clot formation was observed in the operative field, none occurred within the clamped arteries. A total of 191,200 units of UK were employed with no bleeding complications. Following surgery the patient had a palpable pedal pulse and markedly improved perfusion of her toes. She was discharged on aspirin and coumadin on postoperative day five. It is concluded that for patients with HIT, systemic aspirin and dextran combined with local intraarterial UK are a simple and effective substitute for systemic anticoagulation with heparin during arterial reconstruction.