Catheter-directed, ultrasound-assisted thrombolysis is a safe and effective treatment for pulmonary embolism, even in high-risk patients.

OBJECTIVE: We sought to assess the early success and safety of catheter-directed, ultrasound-assisted (CDUA) thrombolysis for acute pulmonary embolism (PE) in patients deemed to be "high risk" for thrombolytic therapy. METHODS: A retrospective evaluation of patients who underwent CDUA pulmonary thrombolysis in our practice during 39 months is reported. There were 91 patients considered, all of whom presented with acute PE as diagnosed by computed tomography angiography. The ratio of the right ventricle to left ventricle diameter (RVaxial:LVaxial) was noted, as were preprocedure pulmonary artery pressures (PAPs). Demographic data, significant medical history, and procedure details were recorded. Standard thrombolysis protocol was followed (1 mg of tissue plasminogen activator per hour per catheter after an initial 2-mg bolus per catheter). Minitab 17 (Minitab Inc, State College, PA) was used for data analysis. RESULTS: There were 91 patients who had a computed tomography diagnosis of acute PE and pulmonary hypertension (PAP >25 mm Hg). Seventeen patients (19%) were deemed to be at high risk for bleeding, predicted by recent hemorrhage, major surgery within 3 weeks, acute myocardial infarction, and cardiac arrest with cardiopulmonary resuscitation within 1 week. The high-risk patients in our study were noted to have higher RV:LV ratios and lower oxygen saturations on admission (P < .05). On computed tomography angiography, the mean pretherapy RVaxial:LVaxial ratio was 1.5 ± 0.4. The mean pretherapy PAP was 56.2 ± 15.2 mm Hg. After 18.5 ± 3.5 hours of thrombolysis, the mean post-therapy PAP was 34.3 ± 10.4 mm Hg, with a pressure drop of 21.9 ± 4.8 mm Hg (39% decrease; P < .001). In total, seven patients (8%) suffered bleeding complications that required intervention-four gastrointestinal bleeds, a rectus sheath hematoma, and one gross hematuria. Three of the seven complications occurred in the high-risk group (3/17) and the other four in the general population of patients (4/74; P = .118). Minor bleeding complications (n = 14 [15%]) did not require intervention and included puncture site hematomas, ecchymosis, and mild traumatic hematuria. Considering all bleeding complications, increasing RVaxial:LVaxial ratio was a predictor of any bleeding complication, independent of all risk factors (P = .005). CONCLUSIONS: CDUA thrombolysis for acute PE effectively reduced mean PAPs. Given the low incidence of major bleeding complications, even in those deemed to be clinically at high risk for bleeding, we additionally conclude that this procedure can be performed safely. Although larger studies with longer follow-up are necessary, CDUA pulmonary thrombolysis for the management of acute submassive PE appears to be effective in decreasing right-sided heart strain and can be performed with an acceptable risk profile.

Adventitial cystic disease of the femoral vein in a 5-year-old boy mimicking deep venous thrombosis.

Adventitial cystic disease of the vein is a rare vascular anomaly with 32 reported cases. A 5-year-old boy initially presented with painless leg swelling. He was misdiagnosed with deep vein thrombosis and treated with 3 months of warfarin. When swelling failed to improve, a magnetic resonance venogram showed a mural cystic lesion of the left common femoral vein. In the operating room, the cyst was excised, relieving the obstructive effect and restoring flow. The swelling resolved within days. This is the first reported case of adventitial cystic disease of the vein occurring in a pediatric patient.

Closed-cell stents present with higher velocities on duplex ultrasound compared with open-cell stents after carotid intervention: short- and mid-term results.

BACKGROUND: The purpose of this study was to evaluate the effect of carotid cell design on duplex ultrasound velocity readings in the immediate postoperative period and over time. METHODS: A prospective database encompassing all patients treated with carotid artery stents between 2003 and 2008 was established and analyzed for stent type (closed-cell vs. open-cell), indications, and comorbidities. Patients were followed up clinically and with duplex ultrasound immediately after surgery, and every 6 months thereafter. Peak systolic velocities (PSV), end diastolic velocities (EDV), and internal carotid artery (ICA) to common carotid artery (CCA) ratios of PSV were recorded. RESULTS: A total of 214 interventions with 157 (73.3%) open-cell and 57 (26.7%) closed-cell types of carotid stents were performed in 205 patients. Two groups were similar regarding demographics, comorbidities, lesions characteristics, and stent length and diameter. The only difference was a significantly higher mean age (74.4 ± 10.1 vs. 70.9 ± 9.7 years; p = 0.027) and a history of myocardial infarction (34.5% vs. 15.6%; p = 0.004) in the closed-cell group versus open-cell group. Immediately after surgery PSV (115.9 ± 66.1 vs. 93.1 ± 38.7 cm/s; p = 0.003) and ICA/CCA ratio (2.08 ± 1.66 vs. 1.45 ± 0.52; p = 0.001) were significantly higher in closed-cell compared with open-cell group. This difference persisted during the follow-up period of 20.2 +/- 16.4 months; PSV (147.2 ± 108.8 vs. 110.0 ± 51.9; p = 0.003) and ICA/CCA ratio (2.61 ± 2.31 vs. 1.76 ± 0.81; p = 0.001). Patients with diabetes and calcified lesions had higher PSV and ICA/CCA ratio immediately after surgery (p > 0.05 and p < 0.05 for those with diabetes and calcified lesions, respectively) and over time. The number of readings showing significant restenosis (PSV >300 cm/s) over time were significantly higher in closed-cell 5 (8.7%) versus open-cell 1 (0.06%). EDV was not statistically different in the two groups (p > 0.05). CONCLUSION: Our study suggests that duplex criteria to screen for poststent restenosis may require modification according to stent-type. However, long-term effect of stent design on restenosis is still to be established.

Endovascular aneurysm repair in nonagenarians is safe and effective.

OBJECTIVES: Advanced age is a significant risk factor that has traditionally steered patients away from open aneurysm repair and toward expectant management. Today, however, the reduced morbidity and mortality of aortic stent grafting has created a new opportunity for aneurysm repair in patients previously considered too high a risk for open surgery. Here we report our experience with endovascular aneurysm repair (EVAR) in nonagenarians. METHODS: Retrospective chart review identified all patients>90-years-old undergoing EVAR over a 9-year period at our institution. Collected data included preoperative comorbidities, perioperative complications, endoleaks, reinterventions, and long-term survival. RESULTS: 24 patients underwent EVAR. The mean age was 91.5 years (range 90-94) among 15 (63%) males and 9 (37%) females. Mean abdominal aortic aneurysm diameter was 6.3±1.1 cm. Eight patients (33%) were symptomatic (pain or tenderness). There were no ruptures. Fourteen patients (58%) had general anesthesia while 10 (42%) had local or regional anesthesia. Mean postoperative length of stay was 3.2±2.4 days (2.8±1.9 days for asymptomatic vs 4.1±3.2 days for symptomatic, P=.29). There was one perioperative mortality (4.2%). There were two local groin seromas (8.3%) and six systemic complications (25%). One patient required reintervention for endoleak (4.2%). There were no aneurysm related deaths beyond the 30-day postoperative period. Mean survival beyond 30 days was 29.7±18.0 months for patients expiring during follow-up. Cumulative estimated 12, 24, and 36-month survival rates were 83%, 64%, and 50%, respectively. Linear regression analysis demonstrated an inverse relationship between the number of preoperative comorbidities and postoperative survival in our cohort (R2=0.701), with significantly decreased survival noted for patients presenting with >5 comorbidities. Those still alive in follow-up have a mean survival of 36.1±16.0 months. CONCLUSION: This is the largest reported EVAR series in nonagenarians. Despite their advanced age, these patients benefit from EVAR with low morbidity, low mortality, and mean survival exceeding 2.4 years. Survival appears best in those patients with ≤5 comorbidities. With or without symptoms, patients over the age of 90 should be considered for EVAR.

Delayed permanent paraplegia after endovascular repair of abdominal aortic aneurysm.

Spinal cord ischemia is a rare complication after abdominal aortic surgery and has been attributed to surgical devascularization of the spinal cord, atheroembolization of the cord circulation, or hypoperfusion of cord structures secondary to hypotension or cord edema. We present a diabetic, hypertensive 75-year-old male with endstage renal disease who presented with a 5.5 cm asymptomatic infrarenal abdominal aortic aneurysm, and concomitant 3.5 cm right common iliac artery aneurysm. After undergoing successful endovascular repair with an aorto-uni-iliac device, unilateral hypogastric artery embolization, and femoral-femoral bypass, he was discharged to a rehabilitation facility neurologically intact with a stage 2 decubitus ulcer. He returned on postoperative day 21 with a large stage 4 septic decubitus ulcer, fever, leukocytosis, hypotension, and paraplegia. We hypothesize that the compromised blood flow from the initial reconstruction, combined with the delayed hypotension imposed by sepsis, resulted in spinal cord infarction. He was eventually discharged to a nursing facility with no improvement in his neurologic status. We report the first case of significantly delayed permanent paraplegia after endovascular abdominal aortic aneurysmorrhaphy.

Ruptured persistent sciatic artery aneurysm managed by endovascular embolization.

Persistent sciatic artery (PSA) is a rare vascular anomaly present in 0.025% to 0.05% of the population. They are particularly prone to aneurysmal degeneration, potentially leading to distal ischemia, sciatic neuropathy, or rarely rupture. Here, we describe a case of a ruptured PSA aneurysm managed by endovascular embolization. A 70-year-old man initially presented with acute left lower extremity ischemia. He was found to have a popliteal embolus originating from a complete persistent sciatic artery aneurysm. He underwent thrombolysis followed by a femoropopliteal bypass and ligation of the proximal popliteal artery to exclude the PSA. Four weeks later he re-presented with severe pain, a pulsatile buttock mass, and anemia in the setting of hemodynamic instability. A ruptured PSA aneurysm was confirmed by computed tomography angiography (CTA). This was managed emergently by endovascular exclusion of the inflow and outflow vessels using Amplatzer vascular plugs. His postoperative course was complicated by both a foot drop, likely secondary to sciatic nerve ischemia, and a buttock abscess. To our knowledge, this is the first report detailing the endovascular management of a ruptured PSA aneurysm. The etiology, management, and complications associated with the treatment of this rare vascular entity are discussed.