Inferior vena cava perforation during percutaneous filter removal.

BACKGROUND: Percutaneous Inferior Venacava (IVC) filter retrieval can be challenging when the filter is grossly angulated, embedded in the wall or penetrates through the IVC. When conventional filter removal technique fails, the use of advanced retrieval techniques often improves the chances of percutaneous filter retrieval. These techniques, however, are associated with a high rate of complications. METHODS: We report a case of 26-year-old female who had IVC filter placed on postpartum day 4. Attempted percutaneous filter retrieval 3 weeks later with loop snare technique and endobronchial forceps assisted filter removal technique resulted in gross filter deformity, malposition, and IVC perforation. RESULT: Open IVC filter removal was performed with midline laparotomy and cavotomy with lateral venorrhapy. The deformed filter along with adherent thrombus was completely removed. The patient had an uneventful recovery with no immediate or long-term complications. CONCLUSION: Use of advanced endovascular IVC filter retrieval techniques could result in serious complications like filter fracture, migration and IVC perforation. Since excessive tilt of the filter at the time of placement often results in difficult retrieval, it is important to ensure proper deployment of the filter with minimal tilt. If encountered with excessively tilted or embedded filter, one should refrain from excessive manipulation of the filter and consider open filter removal.

Use of Indocyanine Green During Repair of a Superior Mesenteric Artery Aneurysm.

Superior mesenteric artery (SMA) aneurysms are rare and associated with a high risk of rupture, with resultant significant morbidity and mortality. During open operative repair of a superior mesenteric artery aneurysm, perfusion of the involved small bowel must be evaluated when determining need for and/or extent of vascular reconstruction. We present a case of a 51-year-old woman who underwent open repair of a non-ruptured superior mesenteric artery aneurysm with ligation and excision, in whom no revascularization was determined to be needed and the involved small bowel was able to be preserved, with intraoperative evaluation of perfusion using indocyanine green (ICG) fluorescence imaging, as an adjunct to more traditional methods of perfusion assessment.

Endovascular repair for blunt thoracic aortic injury using the Zenith Alpha low-profile device.

OBJECTIVE: The objective of this study was to report 30-day results from a prospective, nonrandomized, multicenter trial that evaluated the safety and effectiveness of the Zenith Alpha thoracic endovascular graft (Cook Medical, Bloomington, Ind) for treatment of blunt thoracic aortic injuries (BTAIs). METHODS: Eligible patients with BTAIs (grade II to grade IV) in the descending thoracic aorta were treated with the Zenith Alpha device, which is available in smaller graft diameters (starting at 18 mm) and lower profile delivery systems (starting at 16F) than currently available thoracic endografts. The device (nitinol stents and polyester graft material) accommodates a tighter aortic curvature (radius of 20 mm) than the predicate Zenith TX2 Pro-Form. Follow-up clinical and imaging evaluations were performed at 30 days, at 6 and 12 months, and annually thereafter through 5 years. The primary end point was 30-day mortality. RESULTS: Between January 2013 and May 2014, 50 patients (44 men; mean age, 43 ± 19 years; range, 18-89 years) were treated with the Zenith Alpha device at 17 U.S. sites. The mean Injury Severity Score was 31 ± 14 (range, 3-66). Technical success was achieved in 100% of patients, with 0% intraoperative mortality. Device access was entirely percutaneous in 22 patients (44%). Smaller size grafts (18-24 mm) were used in 15 patients (30%). The mean procedure time was 85 ± 44 minutes (range, 34-278 minutes), and mean blood loss was 103 ± 145 mL (range, 0-1000 mL). The 30-day mortality rate was 2%; one patient died 24 days after the procedure of respiratory failure related to associated injuries and not to the device or procedure as adjudicated by an independent Clinical Events Committee (CEC). One patient experienced a stroke 7 days after the procedure (cause undetermined by the CEC), and one patient underwent reintervention for a site-reported proximal type I endoleak (core laboratory reported unknown endoleak type) at 30 days after the procedure. There have been no conversions to open surgical repair, paraplegia, or aortic rupture within 30 days. CONCLUSIONS: Short-term results indicate that the Zenith Alpha thoracic endovascular graft appears safe and effective for the treatment of BTAIs. This low-profile device enables complete percutaneous repair in a large percentage of patients and can achieve high rates of technical success and very low rates of aortic injury-related mortality within 30 days.

Inferior vena cava filter penetration into right proximal ureter.

Inferior vena cava (IVC) filter penetration into the renal collecting system is an infrequent event. We report a case of IVC filter penetration into the right proximal ureter resulting in gross hematuria, hydronephrosis and stone formation.

Contemporary Review of Traumatic Axillary and Subclavian Artery Injuries at an Urban Level One Trauma Center.

OBJECTIVE: Traumatic axillary and subclavian artery injuries are uncommon. Limited data are available regarding patient and injury characteristics, as well as management strategies and outcomes. METHODS: Retrospective chart review was performed on patients presenting to University of Louisville Hospital, an urban Level One Trauma Center, with traumatic axillary and subclavian artery injuries from 2015-2021. Patients were identified using University of Louisville trauma, radiology, and billing database searches based on ICD9/10 codes for axillary and subclavian artery injuries. Descriptive statistics are expressed as frequencies and percentages. Comparisons were performed using Fisher's Exact and Chi-squared tests. RESULTS: Forty-four patients with traumatic axillary-subclavian arterial injuries were identified for analysis. Blunt and penetrating trauma were equally represented (n = 22 for both). A variety of injury types were seen, including minimal/intimal injury, laceration, pseudoaneurysm, transection, occlusion, and arteriovenous fistula. Management strategies were also variable, including non-operative, endovascular, planned hybrid, open, and endovascular converted to open. In operative patients, revascularization technical success was high (n = 31, 97%) with low likelihood of thrombosis (n = 2, 6%) and no infections. Among all patients, amputation rate was 5% (n = 2) and mortality rate was 9% (n = 3). Regarding arterial involvement, blunt injury was more likely to affect the subclavian (n = 18) than the axillary artery (n = 6) (P = .04). No significant difference was seen in brachial plexus injury based on artery involved (subclavian = 9 vs axillary = 11, P = .14) or mechanism (blunt = 6 vs penetrating = 11, P = .22). Non-operative management was more likely with subclavian artery injury (n = 11) vs axillary artery injury (n = 1) (P = .008). There was no significant difference between decision for non-operative (blunt = 9, penetrating = 3) vs operative (blunt = 13, penetrating = 19) management based on mechanism (P = .09). Transection injury was associated with an open repair strategy (endovascular/hybrid = 1, open/endovascular to open conversion = 11, P = .0003). Of the three patients requiring endovascular to open conversion, two required amputation, which were the only two patients in the study undergoing amputation. CONCLUSIONS: Both open and endovascular/hybrid strategies are useful when treating traumatic axillary and subclavian artery injuries and are associated with high likelihood of revascularization technical success, with low rates of thrombosis or infection, when treated promptly at a trauma center with vascular specialists available. Transection injuries were most often treated with open revascularization. Patients undergoing amputation had blunt transection injuries to the subclavian artery and underwent endovascular to open conversion after failed attempts at endovascular revascularization.

Obstructive jaundice secondary to multiple hepatic artery aneurysms in a 14-year-old boy with neurofibromatosis type 1.

Neurofibromatosis type 1 is the most common inherited disorder of the nervous system, affecting approximately 1 in 3,000 people. A small but significant subset of these patients develop vasculopathies. We present the first reported case of neurofibromatosis type 1 presenting with obstructive jaundice secondary to multiple hepatic artery aneurysms. Therapy included staged coil embolization of the hepatic artery aneurysms and resection of a large retroperitoneal neurofibroma.

Endovascular Repair of Traumatic Infrarenal Aortic Injury in an 8-Year-Old.

The patient is an 8 year-old male presenting to outside facility following high-speed motor vehicle collision in which he was a restrained passenger. CT imaging at that time demonstrated a traumatic infrarenal aortic pseudoaneurysm, extensive pneumoperitoneum and free fluid, and an unstable L2 vertebral body fracture. He underwent exploratory laparotomy with small bowel resection prior to transfer. The patient was left in discontinuity and temporary closed. Vascular surgery was consulted upon arrival to tertiary care children's hospital. The decision was made to proceed with emergent endovascular repair. An aortogram confirmed the location of the aortic disruption well below the renal arteries, superior to the bifurcation. An 11 mm × 5 cm Viabahn covered stent was placed across the injury with adequate proximal and distal seal. This is a case of seatbelt-related pediatric infrarenal aortic injury in the setting of polytrauma. Endovascular repair was pursued in this damage-control setting.

Endovascular Treatment of Innominate Artery Bifurcation Injury with Balloon-Expandable Covered Stents Utilizing Kissing Stent Technique.

Major injury of the innominate artery is traditionally treated with an open repair which is technically challenging, associated with large volumes of blood loss and prolonged operative times. Endovascular treatment with covered stent placement across the injury is an attractive alternative. However, placement of a single covered stent across the innominate artery bifurcation into one of its distal branches will not prevent bleeding because of retrograde perfusion from the unstented branch distal to the bifurcation. Here, we report a case of successful endovascular repair of one such injury involving the innominate artery bifurcation with ongoing extravasation into the mediastinum. The injury was successfully treated by utilizing 2 balloon-expandable covered stents placed in kissing fashion from the innominate artery into both of its distal branches. This technique of parallel covered stent placement across a bifurcation could effectively repair bifurcation injuries while maintaining patency of both distal branches.

A Large True Brachial Artery Aneurysm in an Infant.

A 6-month-old male was admitted to the children's hospital for management of an underlying gastrointestinal illness. During his admission, a large, pulsatile mass was incidentally noted in the left upper arm concerning for an expanding pseudoaneurysm. Vascular surgery was consulted, and further workup with a CT angiogram demonstrated a brachial artery aneurysm 3 cm in greatest diameter. The patient was taken to the operating room, where lateral aneurysmorraphy was performed without complication. His neurovascular exam remained intact postoperatively. The presented case demonstrates a viable approach to the surgical management of this clinical challenge in infants. Although reports of brachial artery aneurysm in this age group are rare in the literature, resection with primary repair and interposition grafting have also been described. Long-term outcomes are not available in these cases. Lateral aneurysmorraphy allows for ongoing monitoring and future resection and bypass of the aneurysm as the patient continues to grow.

Endovascular Repair of Transected Axillary Artery via Snare Assisted Through and Through Femoral to Brachial Artery Access.

Axillary artery injury is a rare but complex surgical problem that often requires challenging exposures, lengthy operations, and morbid outcomes for repair. For these reasons, endovascular repair is an attractive alternative as it obviates many of the challenges present with open repair. While pseudoaneurysms, dissections, and short segment injuries with limited arterial disruption are regularly treated endovascularly, complete arterial transections are almost exclusively treated with open repair as obtaining wire access across the site of injury is often not possible. Here we report a case of successful endovascular repair of a completely transected axillary artery with the use of snare assistance to obtain through and through femoral to brachial artery access. This ultimately allowed for covered stent deployment across the axillary transection restoring distal blood flow. Snare assistance in obtaining through and through access across areas of complete transection can allow for increased use of endovascular repair.

Hybrid Endovascular Treatment of Dysphagia Lusoria: Report of 2 Cases.

Dysphagia Lusoria is a condition when aberrant right subclavian artery (ARSA) causes esophageal compression. We report 2 cases of Dysphagia Lusoria treated by hybrid endovascular technique which included subclavian to carotid transposition and embolization of origin of ARSA. By using this technique, we avoided the need for thoracotomy. Both patients had complete symptom relief without any surgery related complication.

Endovascular Rescue of Sheath Perforation During Inferior Vena Cava Filter Retrieval.

INTRODUCTION: Inferior vena cava (IVC) filter retrieval is generally a straightforward procedure but can be challenging with unique complications. A technique used for endovascular rescue of a patient where sheath perforation by the IVC filter occurred during IVC filter retrieval is described. REPORT: A 75 year old man underwent retrieval of an IVC filter that had been in place for 10 months. Using the IVC filter retrieval set from a standard right internal jugular vein approach and the loop-snare technique, the hook and collet were captured, and the filter was collapsed into the retrieval sheath. Approximately halfway through removal of the filter through the sheath, mild resistance was encountered and the tip of the IVC filter was found to have perforated the side of the retrieval sheath. The sheath appeared to have bent slightly in this region, probably weakening the sheath wall and creating angulation, which allowed sheath perforation to occur. From a right common femoral vein approach, an Amplatz wire was used to cannulate the distal end of the perforated sheath. A balloon was then used to pull the perforated sheath with the IVC filter into a larger sheath. After removing the Tuohy-Borst and Luer adapters on the perforated sheath, it was able to be internalised and removed via the femoral vein sheath. DISCUSSION: The endovascular rescue technique described herein may prove useful to other practitioners encountering similar situations, and the complication shows areas of caution when using the loop-snare retrieval technique.

Percutaneous thrombectomy of mural aortic thrombus using intravascular ultrasound guidance.

Mural aortic thrombus is a challenging clinical problem with significant potential complications. Particularly precarious are situations with involvement of the visceral segment of the aorta. We describe a technique for percutaneous thrombectomy of mural aortic thrombus using intravascular ultrasound to guide an angled mechanical thrombectomy catheter in conjunction with a continuous aspiration system (Indigo mechanical thrombectomy system; Penumbra, Alameda, Calif). Use of this technique in three patients with challenging cases of mural aortic thrombus is discussed. All patients were treated successfully and without complication using this technique.

Improving Surveillance of Traumatic Thoracic Aortic Injuries Repaired with Thoracic Endovascular Graft Placement.

The optimal follow-up protocol for patients undergoing thoracic endovascular aortic repair (TEVAR) for traumatic thoracic aortic injury remains unclear. The objective of this study was to assess follow-up patterns in such patients and present an approach to improve long-term follow-up in this cohort. The University of Louisville Trauma Registry was queried for patients who underwent TEVAR for traumatic thoracic aortic injuries between 2006 and 2016. Demographic, injury-specific, perioperative, and outcome measures were recorded for each patient. Follow-up evaluation and duration of follow-up were captured. Follow-up imaging was reviewed for any evidence of vascular complications. A total of 56 patients underwent TEVAR for traumatic thoracic aortic injury. Median age was 48 (range 18-86). Injury mechanism was largely blunt trauma (55 (98%)). Median injury severity score was 34 (range 17-43). Median length of stay was 12.5 days (range 1-40 days), and 51 patients (91%) survived to discharge. Of these, 30 (54%) made at least one follow-up appointment, and 21 of those 30 (70%) received a follow-up CT scan. Median time to last follow-up was one month (range 0-48 months), with 12 patients (21%) having follow-up beyond two months. No patients demonstrated any evidence of vascular complications on imaging at last follow-up. Despite the increased use of TEVAR to treat traumatic aortic injuries, limited follow-up data exist to predict the long-term outcomes of such interventions. Development of statewide or regional databases may help better track outcomes and identify late complications.

Adrenomedullin and adrenomedullin-binding protein-1 downregulate inflammatory cytokines and attenuate tissue injury after gut ischemia-reperfusion.

BACKGROUND: Recent studies have shown that adrenomedullin (AM) and AM-binding protein-1 (AMBP-1) possess anti-inflammatory properties in sepsis. We hypothesized that administration of AM/AMBP-1 after gut ischemia-reperfusion (I/R) downregulates inflammatory cytokines and attenuates tissue injury. METHODS: Male Sprague-Dawley rats (275-325 g) were used. Gut ischemia was induced by placing a microvascular clip across the superior mesenteric artery (SMA) for 90 minutes. Upon release of the SMA clamp, the animals were treated by AM (12 microg per kilogram of body weight) and AMBP-1 (40 microg per kilogram of body weight) in combination, or vehicle (1 mL 0.9% NaCl) over 30 minutes via a femoral vein catheter. The animals undergoing sham operation or ischemia for 90 minutes only, did not receive AM/AMBP-1 treatment. At 60 minutes after the completion of the treatment (ie, 90 minutes after reperfusion), blood samples were collected. Plasma AM and AMBP-1 were measured by radioimmunoassay and Western blot analysis, respectively. Serum levels of TNF-alpha, interleukin (IL)-1beta, IL-6, IL-10, transaminases (ie, alanine aminotransaminase, aspartate aminotransaminase), lactate, and creatinine were determined with the use of enzyme-linked immunosorbent assay and other standard methods. In additional groups of animals, the 10-day survival rate was recorded after gut I/R. RESULTS: Ischemia alone was sufficient to downregulate both AM and AMBP-1. Unlike AMBP-1 that remained decreased, AM levels increased significantly after reperfusion. I/R but not ischemia alone significantly increased serum levels of inflammatory cytokines. Moreover, I/R-induced tissue injury was evidenced by increased levels of transaminases, lactate, and creatinine. Administration of AM/AMBP-1 after ischemia, however, markedly reduced cytokine levels, attenuated tissue injury, and improved survival. CONCLUSIONS: AM/AMBP-1 may be a novel treatment to attenuate the reperfusion injury after gut ischemia.

Adrenomedullin and adrenomedullin binding protein-1 prevent acute lung injury after gut ischemia-reperfusion.

BACKGROUND: Ischemic bowel remains a critical problem, resulting in up to 80% mortality. Acute lung injury, a common complication after intestinal ischemia/reperfusion (I/R), might be responsible for such a high mortality rate. Our previous studies have shown that administration of a novel vasoactive peptide adrenomedullin (AM) and its binding protein (AMBP-1) reduces the systemic inflammatory response in rat models of both hemorrhage and sepsis. It remains unknown whether administration of AM/AMBP-1 has any protective effects on intestinal I/R-induced acute lung injury. We hypothesized that administration of AM/AMBP-1 after intestinal I/R prevents acute lung injury through downregulation of proinflammatory cytokines. STUDY DESIGN: Intestinal I/R was induced by placing a microvascular clip across superior mesenteric artery (SMA) for 90 minutes in adult male Sprague-Dawley rats (275 to 325 g). On release of the SMA clamp, the animals were treated with either AM (12 mug/kg body weight) in combination with AMBP-1 (40 microg/kg body weight) or vehicle (1 mL normal saline) during a period of 30 minutes through a femoral vein catheter. Lung samples were collected at 4 hours after treatment or sham operation. Lung injury was assessed by examining lung water content, morphologic changes, and granulocyte myeloperoxidase activity. Tumor necrosis factor-alpha and interleukin-6 gene expression and their protein levels in the lungs were measured by reverse transcription-polymerase chain reaction and enzyme-linked immunosorbent assay, respectively. In additional groups of animals, AM/AMBP-1 or vehicle was administered at 1 hour after onset of reperfusion. Lung histology was examined at 3 hours after treatment. RESULTS: Intestinal I/R induced considerable lung injury, as characterized by lung edema, histopathologic changes, increased myeloperoxidase activity, and proinflammatory cytokines (tumor necrosis factor-alpha and interleukin-6) levels in the lungs. Administration of AM/AMBP-1 after ischemia mitigated lung injury and dramatically downregulated proinflammatory cytokines. Lung injury was also ameliorated by delayed AM/AMBP-1 treatment as evidenced by improvement in lung histology. CONCLUSIONS: AM/AMBP-1 can be developed as a novel treatment to attenuate acute lung injury after an episode of gut ischemia. The protective effect of AM/AMBP-1 appears to be mediated through downregulation of proinflammatory cytokines.

Aortic debranching for descending thoracic aortic aneurysm repair by stent grafts.

Endovascular repair of a descending thoracic aortic aneurysm may result in covering the ostia of the left carotid or left subclavian artery for proper proximal landing zones, and the celiac artery or superior mesenteric artery ostia in the abdomen for distal landing zones. To prevent possible complications of occluding the ostia of these vessels, the authors performed an innominate to left common carotid and left subclavian artery bypass as the first procedure in one patient. In the second patient they performed an aortoceliac and aortomesenteric bypass before stent graft placement. The stent graft repair of the descending thoracic aortic aneurysm was performed subsequently in both patients. This aortic debranching provides subsequent proper placement of thoracic stent grafts.

Endovascular treatment of false aneurysm of the thyrocervical trunk.

The thyrocervical trunk is the second superior branch off the subclavian artery. Pseudoaneurysm of the thyrocervical trunk has been reported after attempted internal jugular vein cannulation for central venous or hemodialysis access. The treatment of pseudoaneurysms of the thyrocervical trunk depends on the findings from color flow Doppler ultrasonography and angiography. Although pseudoaneurysms of the thyrocervical trunk are rare, the treatment options should be clear. Surgical ligation is an effective technique that is safe and well-defined, but control through a cervical incision may be difficult. Endovascular treatment of the pseudoaneurysm may be accomplished with coil embolization of the artery, which is described.

Successful Percutaneous Retrieval of IVC Filter with Wide Retroperitoneal Penetration Presenting with Gastrointestinal Bleeding.

Symptomatic penetration of the retroperitoneal structures by inferior vena cava (IVC) filter is a rare clinical entity. Vast majority of these patients require laparotomy and open retrieval of the filter. We report a case of a filter penetrating into the duodenum within two months of implantation resulting in gastrointestinal bleeding. The patient was successfully managed with percutaneous retrieval of the filter, blood transfusion and serial abdominal examination thus avoiding laparotomy.

Giant mesenteric fibromatosis presenting as small bowel obstruction.

Mesenteric fibromatosis is a proliferative fibroblastic neoplasia of the small intestine mesentery that may occur as a unique or multiple formation. Mesenteric fibromatosis is a rare, locally aggressive neoplasm and may present with abdominal discomfort, abdominal pain, weight loss, or symptoms of ureteral obstruction, mesenteric ischemia, or intestinal obstruction. It is of the utmost importance to distinguish mesenteric fibromatosis from gastrointestinal stromal tumors. Histopathology accurately differentiates between these two distinct entities. The preferred treatment is local surgical excision with a margin of uninvolved tissue. The involvement of important structures like the superior mesenteric artery and the superior mesenteric vein may pose a challenge during resection, but these tumors can be excised and the vessels repaired primarily.