Management of intra-aortic balloon pump entrapment: a case report and review of the literature.

An intra-aortic balloon pump is one of the most valuable tools in the cardiac surgeon's armament to assist in the management of the failing heart. Despite its widespread use, there are associated risks and complications, one of which is balloon rupture with associated entrapment. Numerous approaches for dealing with this complication have been described; here we review the previous experience with intra-aortic balloon pump entrapment and discuss potential management, with particular reference to a recent case of our own.

Limb occlusion after endovascular repair of an abdominal aortic aneurysm: beware the narrow distal aorta.

PURPOSE: This case aims to highlight the need for careful scrutiny of the distal aorta during endovascular aneurysm repair (EVAR) planning to avoid potentially avoidable graft limb occlusion. CASE REPORT: We present a case of graft limb occlusion after EVAR, unresponsive to endovascular re-intervention requiring surgical extra-anatomic revascularization, due to a narrow distal aorta causing graft impingement and collapse. CONCLUSION: We suggest clinicians should be aware of this potential pitfall during EVAR planning and beware the narrow distal aorta.

Long-term results of percutaneous transhepatic cholangiographic drainage for palliation of malignant biliary obstruction.

INTRODUCTION: Percutaneous stenting is established in the palliation of malignant biliary obstruction. We examined the indications, success rate, complications, and long-term postoperative course of patients undergoing this procedure. METHODS: All patients undergoing percutaneous transhepatic cholangiography (PTC) and metal stenting over a 12-month period in a tertiary referral center were studied. Data regarding diagnosis, number and type of procedures, complications, and survival were collected from multidisciplinary case notes and general practitioner records. RESULTS: There were 21 patients of median age 70 (mean, 71; range, 54-93), 56.5% (11) had pancreatic cancer and 33% (7) cholangiocarcinoma. The mean number of PTC procedures was 2.43 and mean length of stay in hospital 20.66 days (range, 3-99). Serum bilirubin fell post drainage from 397 to 226 (µmol/L; p < 0.001) on discharge, however, in 19% (4) there was no significant reduction. Complications included cholangitis (19%) and acute pancreatitis (10%). Mortality was high and 9 patients (43%) died within 30 days, of whom 2 died in the hospital (1 from ascending cholangitis and another from pneumonia). The median time between discharge and death was 25 days (mean, 59.1 days) and no patient was alive after 193 days. CONCLUSIONS: The prognosis following PTC stenting of malignant biliary obstruction is extremely poor despite adequate drainage. The procedure can lead to significant morbidity and a lengthy hospital stay. Patient selection is therefore of paramount importance and an expedient treatment protocol and early return home recommended.

Brachial artery aneurysm following open repair of posttraumatic false aneurysm and arteriovenous fistula.

True brachial artery aneurysms remain extremely rare and are most commonly related to repetitive blunt trauma. Although operative repair of false aneurysms is well established, management of true aneurysms is varied due to their rarity. We present a true brachial artery aneurysm, in a 55-year old male, which occurred some 22-years following the repair of a posttraumatic false aneurysm. Following arterial duplex and computerised tomography, aneurysectomy with reversed interposition vein graft was performed.

Successful endovascular treatment of multiple mesenteric arterial aneurysms associated with alpha-1-antitrypsin deficiency.

We present a rare case of a patient who presented with acute abdominal pain with a previous history of alpha-1-antitrypsin deficiency (alpha1-antitrypsin deficiency). Further clinical deterioration necessitated computed tomography (CT) imaging, which demonstrated a hemoperitoneum. Angiography confirmed the rupture of multiple aneurysms originating from the mesenteric arterial arcade, which were treated successfully with endovascular embolization. The association between mesenteric arterial aneurysm rupture and alpha-1-antitrypsin deficiency is explored.

Testicular infarction: a rare complication of endovascular aneurysm repair treatment for aortoiliac aneurysm.

Endovascular aneurysm repair (EVAR) is an established therapy to prevent rupture in large infrarenal abdominal aortic aneurysms (AAA). As experience with this therapy has grown, treatment of more challenging anatomy has led to the identification of several new procedurally related complications. We report the case of a 67-year-old man with an asymptomatic, large infrarenal AAA with an associated left common iliac artery aneurysm. Endovascular therapy for an aortoiliac aneurysm involved prior coil embolization of his left internal iliac artery to allow conventional EVAR with extension to the external iliac artery of the left graft limb, thus excluding the left iliac aneurysm. He presented 6 weeks postoperatively with onset of left-sided scrotal pain and underwent emergency orchidectomy for ischemic infarction of his left testis. The histology report confirmed that the left testis was necrotic secondary to a thrombus in the testicular artery. To our knowledge, this is the first report of testicular infarction after EVAR.

Prosthetic stent graft infection after endovascular abdominal aortic aneurysm repair.

OBJECTIVE: The purpose of this report is to discuss the incidence, diagnosis, and management of stent graft infections after endovascular aneurysm repair (EVAR). METHODS: Data were collected from the hospital database and medical case notes for all patients with infected endografts after elective or emergency EVAR for abdominal aortic aneurysm (AAA) during the last 8 years in two university teaching hospitals in Northern Ireland. The data included the patient's age, gender, presentation of sepsis, treatment offered, and the ultimate outcome. The diagnosis of graft-related sepsis was established by a combination of investigations including inflammatory markers, labelled white cell scan, computed tomography (CT) scan, microbiology cultures, and postmortem examination. RESULTS: Graft-related septic complications occurred in six of 509 patients, including 433 elective repairs and 76 emergency endografts for ruptured AAA. Two patients presented with left psoas abscess and were treated successfully with extra-anatomic bypass and removal of the infected stent graft. Two more patients presented with infected graft without other evidence of intra-abdominal sepsis: one underwent successful removal of the infected prosthesis with extra-anatomical bypass, and the other was treated conservatively and died of progressively worsening sepsis. The fifth patient presented with unexplained fever and died suddenly, with a postmortem diagnosis of aortoenteric fistula and ruptured aneurysm. The last patient presented with an aortoenteric fistula, was treated conservatively in view of concurrent myelodysplasia, and died of possible aneurysm rupture. CONCLUSION: This report emphasizes the need for continued awareness of potential graft-related septic complications in patients undergoing EVAR of AAA. Attention to detail with regard to sterility and antibiotic prophylaxis during stent grafting and during any secondary interventions is vital in reducing the risk of infection. In addition, early recognition and prompt treatment are essential for a successful outcome.

The use of direct thrombin injection to treat a type II endoleak following endovascular repair of abdominal aortic aneurysm.

This report describes the use of thrombin to treat a type II endoleak which was causing continued abdominal aortic aneurysm expansion in a patient who had undergone endovascular repair. A small quantity of thrombin was injected into the leak by a percutaneous approach directly into the aneurysm sac using color doppler ultrasound. The procedure was successful and required only a few minutes to perform. We believe this procedure is an alternative to some of the more complex and technically challenging means of treating this lesion.