Management of non-giant cell arteritis disease of the superficial temporal artery.

Non-giant cell arteritis disease of the superficial temporal artery (STA) is rare, appearing only as case reports in the literature. There were nine patients with STA pathology. STA aneurysm (n = 1), pseudoaneurysm (n = 4), thrombosis (n = 1), and arteriovenous malformation (n = 3). Four patients had ligation and excision, three had percutaneous interventions and one had a combination of both. All patients had immediate technical success and eight of the nine total patients had follow-up. We present a variety of ways to approach these unusual pathologies with percutaneous and open techniques demonstrating very good early outcome.

Improving retrieval rates of temporary inferior vena cava filters.

PURPOSE: Most studies have shown that the rate of inferior vena cava filter (IVCF) retrieval rarely exceeds 30%. A review of practices in our own institution revealed similar results (18%). Within the last year, few centers have demonstrated improved retrieval rates. Our hypothesis was that developing a dedicated program would improve IVCF retrieval. We report the results of an ongoing study following the development of this program. METHODS: This is a cohort of nontrauma consecutive patients who had an IVCF placed by the vascular service over a 12-month period (January 2010-January 2011) and were followed prospectively. A dedicated nurse practitioner was responsible in developing a database, maintaining contact with all the patients, and ensuring that arrangements were made for retrieval when indications for IVCF protection were no longer present. Demographics, indication for filter placement, timing to filter retrieval, and complications during placement and retrieval were prospectively collected. Retrieval rate was compared to the baseline institution data. RESULTS: During the study period, 42 patients had an IVCF placed. There were 27 men and 15 women with a mean age of 58 (25 to 88 years old). Two patients were excluded (one due to mortality and one had multiple filters) leaving 40 patients in the study. Indications for IVCF placement were absolute in 23 of 40 patients (58%), relative in 10 of 40 patients (25%), while seven patients (17%) had an IVCF placed for prophylaxis as they were considered high risk for pulmonary embolism (PE) and could not receive any chemical regimen. During follow-up, five filters were converted to permanent. Therefore, retrieval was successful in 19 of 22 patients with an 86% success rate and no complications. Median time to retrieval was 21 days ranging from 4 to 140 days. Retrieval rate for IVCFs designated as temporary at the time of placement was 70% (19 of 27), which was significantly higher compared to our baseline data of 18% (P < .001). CONCLUSION: Initial data show that a dedicated program that closely monitors patients with temporary IVCFs for ongoing need of filter prophylaxis can result in high retrieval rates. The endurance and long-term success of such a program needs to be further validated.

Management of true aneurysms of hemodialysis access fistulas.

OBJECTIVES: This study was designed to determine the clinical presentation, characteristics, and management of true aneurysms in dialysis access fistulas. METHODS: Patients presenting with symptoms or functional arteriovenous fistula (AVF) problems and aneurysmal enlargement of the outflow vein were evaluated with duplex ultrasound scans. Dilatation to more than three times the native vessel diameter was considered aneurysmal. Pseudoaneurysms were excluded from the study. Patients' demographics, aneurysm characteristics (diameter, location, thrombus, association with stenosis, and outflow obstruction), symptoms, type of treatment, and follow-up were recorded. RESULTS: Twenty-three patients with a mean age of 55 years were found to have 29 upper extremity aneurysms of the outflow vein on duplex ultrasound scan. Nine patients (39%) had radiocephalic, 11 patients (48%) had brachiocephalic, 2 patients (9%) had brachiobasilic, and 1 patient (4%) had radiobasilic arteriovenous fistula. The average aneurysm size was 3.3 cm and the mean time from fistula placement to treatment was 47.1 months. Four patients (17%) were asymptomatic and were repaired due to technical and mechanical problems with AVFs, including stenosis and lack of normal vein for cannulation, compromising continued use. Nineteen patients (83%) presented with symptoms, including pain (48%), skin changes (30%), venous hypertension (22%), steal syndrome (22%), and high output failure (9%). Four patients (17%) were found to have outflow vein stenosis, 2 patients (9%) had central venous stenosis, and 2 patients (9%) had central venous occlusion. In 13 patients (56%) who had a functioning kidney transplant, the fistula was ligated with or without aneurysm excision. Three of the 13 patients developed superficial phlebitis with 1 patient requiring surgical evacuation of a clot; the other 2 patients were managed conservatively. Two of the 13 patients required creation of new access due to renal transplant failure. In the remaining 10 patients, the aneurysm was treated and the fistula salvaged due to a persistent need for hemodialysis. The median follow-up of these patients was 19 months ranging from 8 to 25 months. Seven patients (30%) underwent excision and repair with the great saphenous vein and 3 patients (13%) had excision and repair with prosthetic material, 2 of which underwent central venous angioplasty and stenting. Two patients developed thrombosis of their repair requiring new access in the contralateral arm. Three patients needed secondary percutaneous interventions for anastomotic stenosis. CONCLUSION: Although true aneurysms in patients with dialysis access are uncommon, significant complications may occur as a consequence of their presence. These complications can be treated and the fistulas can usually be salvaged.

Recurrent popliteal vein aneurysm.

A 28-year-old female presented with a soft mass in the left popliteal fossa. She had a popliteal vein aneurysm repair 4 years ago. Magnetic resonance venography and ultrasound revealed a recurrent saccular aneurysm on the site of the repair. It measured 3 x 4 cm and had no thrombus. The aneurysm was resected, and as the vein had adequate length, it was primarily repaired with an end-to-end anastomosis. She was placed on coumadin for 3 months. At follow-up, the vein was competent and free of thrombosis.

Hybrid Aortic Arch Repair Using a Ministernotomy.

Hybrid thoracic endovascular aortic repair with surgical arch debranching is an accepted method for total arch reconstruction. Although off-pump arch debranching is increasingly used as a prophylactic adjunct to endovascular arch repair extending into landing zone 0, this technique is seldom performed with a ministernotomy due to a steep learning curve among surgeons. Herein, we report our standard technique for off-pump hybrid total aortic arch repair using a ministernotomy.

Review of indications and practices of vena caval filters at a large university hospital.

BACKGROUND: Vena caval filter (VCF) use has been increasing in recent years. Prophylactic VCF placement has been applied liberally in high-risk patients. METHODS: Consecutive patients with VCF placement over a 2-year period at a university hospital were reviewed. RESULTS: A total of 244 patients underwent VCF placement in 2 years. Of all, 54% of the patients had the VCF placed for an absolute indication, 14% for a relative indication, and 32% for prophylaxis. Only 14 (9%) of the retrievable filters were removed. Eight patients had a complication of VCF placement; there were no complications of filter retrieval. Vena caval filter placement for prophylaxis alone was 57% from the division of trauma and surgical critical care, 18.3% from interventional radiology department, and 5.2% from the division of vascular surgery. CONCLUSIONS: This study indicates that many VCFs are placed for prophylaxis. A low percentage of VCFs was retrieved. This may be the practice at many other large university-based hospitals, necessitating strategies for reducing their placement.