Application of the Preventable Shunt Revision Rate to an Adult Population.

BACKGROUND: The preventable shunt revision rate (PSRR) was recently introduced in pediatric hydrocephalus as a quality metric for shunt surgery. We evaluated the PSRR in an adult hydrocephalus population. METHODS: All ventricular shunt operations (January 1, 2013 to March 31, 2018) performed at a university-based teaching hospital were included. For any index surgery (de novo or revision) resulting in reoperation within 90 days, the index surgery details were collected, and a consensus decision was reached regarding whether the failure had been potentially avoidable. Preventable failure was defined as failure due to infection, malposition, disconnection, migration, or kinking. The 90-day shunt failure rate and PSRR were calculated. Bivariate analyses were performed to evaluate the individual effects of each independent variable on preventable shunt failure. RESULTS: A total of 318 shunt operations had been performed in 245 patients. Most patients were women (62%), with a median age of 48.2 years (interquartile range, 31.2-63.2 years). Most had had ventriculoperitoneal shunts placed (86.5%), and just more than one half were new shunts (51.6%). A total of 53 cases (16.7%) in 42 patients experienced shunt failure within 90 days of the index operation. Of these, 27 failures (8.5% of the total cases; 51% of the failures) were considered potentially preventable. The most common reasons were infection (37%; n = 10) and malposition of the proximal and distal catheters (both 25.9%; n = 7). Age was the only statistically significant difference between the 2 groups, with the patients experiencing preventable shunt failure older than those without preventable shunt failure (51.4 vs. 37.1 years; P = 0.017). CONCLUSIONS: The 90-day PSRR can be applied to an adult population and serve as a quality metric.

Endocarditis: An Ever Increasing Problem in Cardiac Surgery.

BACKGROUND: Endocarditis remains one of the most threatening diagnoses in cardiac surgery and is still increasing. Particularly, device-related as well as prosthetic endocarditis appears to be on the rise. Early mortality and periprocedural complications are high jeopardizing the success of surgical efforts. We looked at the development of the numbers and the distribution of endocarditis in an all-comer analysis. METHODS: From 2003 to 2017, 752 patients with endocarditis were transferred to our cardiosurgical institution (mean age 65 ± 13 years; mean logistic EuroSCORE 28.01%; males 74.33%). A total of 89.49% of them were surgically treated; 30.01% redo cases thereof; and 9.17% had been operated previously for acute endocarditis. RESULTS: While the total number of cardiosurgical procedures remained relatively stable throughout the years, 20 patients were admitted in 2003 and 79 in 2017 yielding more than fourfold increase (p < 0.001). Early mortality of all patients was 25.1%. Septic emboli occurred in 23.7% and 43.8% cerebral emboli thereof. A significant increase of aortic, mitral, and tricuspid valves involvement was observed (p < 0.001). An increase of device-related endocarditis was also noted (p < 0.001). CONCLUSION: Endocarditis remains a serious problem with high early mortality and morbidity. The vast increase of electrophysiological device implantations has resulted in an increase of tricuspid valve involvement. Liberalization of endocarditis prophylaxis, that is, more restrictive use of antibiotics in 2007 may have at least partially contributed to an increase of the individual risk to suffer from acute endocarditis. A renaissance of a stricter endocarditis-prophylaxis may thus be considered.

[Subdural Hematoma after Open Heart Surgery for Infective Endocarditis Presenting with Pre-operative Intracranial Hemorrhage Infarction;Report of a Case].

A 47-year-old woman with a history of radiation enteritis and implantation of a central venous port was admitted to our intensive care unit(ICU) suffering from high fever. She was diagnosed with active infective endocarditis due to catheter-related blood stream infection. Although echocardiography showed a large vegetation on the mitral valve, surgical therapy was postponed for 5 weeks because of intracranial hemorrhage infarction. On the 3rd day after mitral valve repair, she developed consciousness disturbance and computed tomography(CT) revealed acute subdural hematoma of the posterior cranial fossa. Fortunately, she fully recovered from the neurological complication without surgical intervention.

Infected multilocular hydrocephalus treated by rigid and flexible endoscopes with electromagnetic-guided neuronavigation: a case report.

BACKGROUND: Endoscopic surgery assisted by a navigation system has greatly aided treatment of infected multilocular hydrocephalus, especially in children. CASE REPORT: We describe a 2-year-old boy with multilocular hydrocephalus caused by repeated shunt infection, presenting with fever and vomiting. Magnetic resonance images (MRI) showed extraventricular cysts and severe ventricular deformity. There were three ventriculoperitoneal shunts and one residual ventricular catheter. With a flexible endoscope, we fenestrated the wall of extraventricular cysts and removed the residual catheter. We then used a rigid endoscope to fenestrate ventricular components. Both procedures were guided by electromagnetic (EM) navigation, and hydrocephalus was controlled with one ventricular catheter. CONCLUSION: We have successfully treated a case suffered from infected multilocular hydrocephalus in infants using rigid and flexible endoscopes combined with EM navigation.

Severe Neutropenia at the Time of Implantable Subcutaneous Chest Port Insertion Is Not a Risk Factor for Port Removal at a Tertiary Pediatric Center.

PURPOSE: To determine if severe neutropenia at the time of chest port insertion is a risk factor for port removal and central catheter-associated bloodstream infection (CCABSI) in pediatric patients. MATERIALS AND METHODS: From May 2007 to June 2015, 183 consecutive patients (mean age, 9.9 y; range, 0.75-21 y) had a port inserted at a single tertiary pediatric center. Seventy-two had severe neutropenia at the time of port insertion (absolute neutrophil count [ANC] range, 0-500/mm3; mean, 185/mm3). Follow-up until port removal or death and CCABSI events were recorded. RESULTS: Within the first 30 days, similar incidences of CCABSI (12.5% of patients with severe neutropenia [n = 9] vs 4.5% of patients without [n = 5]), port removal for infection (2.8% [n = 2] vs 2.7% [n = 3]), and local port infection (2.8% [n = 2] vs 0.9% [n = 1]) were observed in both groups (P > .05), but the rate of CCABSI per 1,000 catheter-days was higher for patients with severe neutropenia (P = .045). Overall, similar incidences of CCABSI (18.1% [n = 13] vs 16.2% [n = 18]), port removal for infection (2.8% [n = 2] vs 7.2% [n = 8]), local port infection (2.8% [n = 2] vs 2.7% [n = 3]), and CCABSIs per 1,000 catheter-days (0.332 vs 0.400) were observed in both groups (P > .05). CONCLUSIONS: Port placement in patients with severe neutropenia can be performed without an increased incidence of port removal for infection. The majority of CCABSIs were successfully treated without port removal.

Interventional Laser-assisted Extraction of an Infected Trapped Ventriculoatrial Shunt Based on Techniques for Pacemaker Lead Explantation.

We present a case of successful interventional laser-assisted extraction of an endovascularly trapped long-term implanted ventriculoatrial shunt in a patient with shunt-associated septicemia. This approach is based on modified techniques for explantation of pacemaker leads and might be considered an additional option for extraction of otherwise nonremovable trapped endovascular catheters in experienced centers.

Rupture of Subcutaneous Peritoneal Dialysis Catheter by Stretching Exercise: A Case Report.

Rupture of the peritoneal dialysis (PD) catheter is rare complication. Here, we report a case of catheter rupture that occurred because of exercise after partial catheter reimplantation.A 66-year-old man with a history of end-stage kidney disease secondary to diabetic nephropathy experienced refractory exit-site and tunnel infection. After the infected parts of the catheter were excised, a partial catheter reimplantation was performed. At the time of that surgery, a presternal location was selected for the new exit site, and a titanium extender was used to connect the two catheters. The patient was discharged on postoperative day 3, but was readmitted for a pericatheter leak 5 days later. Fluoroscopy performed to investigate the cause demonstrated a pericatheter leak from the connecting portion between the titanium extender and the catheter.Surgery performed to repair the leak revealed that the catheter had ruptured. We believe that the cause of the rupture was mechanical stress induced by the patient's stretching exercise program. The PD catheter was made of silicone rubber with high elasticity. Even when such resilient materials are used, we recommend that, to avoid PD catheter rupture after partial reimplantation, clinicians should discourage the patient from stretching excessively.

Infections Caused by Rapidly Growing Mycobacteria spp in Children and Adolescents With Cancer.

BACKGROUND: Rapidly growing mycobacteria (RGM) infections in pediatric oncology patients have not been completely characterized. METHODS: We reviewed medical records of oncology patients at St. Jude Children's Research Hospital (St. Jude) from 1990 to 2010 with RGM infections and summarized the results of previously published cases. RESULTS: Twenty-five St. Jude patients had 27 episodes of infection. Approximately half of the cases occurred in patients with hematological malignancies and in males; infections were more common in white patients. Most patients were not neutropenic or lymphopenic. The most common causative species were Mycobacterium chelonae, Mycobacterium abscessus, and Mycobacterium fortuitum. Most isolates were susceptible to amikacin and clarithromycin; all were susceptible to at least 1 of these. Treatment regimens varied considerably, particularly with respect to the duration of antimicrobial chemotherapy. Two St. Jude patients died; both had pulmonary infections. The literature search identified an additional 58 cases of infection. Localized catheter-associated infections were more common than bloodstream infections in the current series than in previous reports, and outbreaks were not recognized. Otherwise, the demographic and clinical characteristics of patients were similar. CONCLUSIONS: Localized catheter-associated infections were most common in this largest reported single center experience reported to date. Pulmonary infection is uncommon in children but, as in adults, has a high mortality rate. Relatively short-term antimicrobial treatment and surgical debridement of infected tissue, if present, may be as effective for catheter-associated infections as prolonged antimicrobial use and may reduce adverse drug effects in these patients, who are vulnerable to drug-drug interactions and toxicity.

Carotid Subclavian Bypass and Stent Grafting for Mycotic Pseudoaneurysm of Right Subclavian Artery.

BACKGROUND: The occurrence of mycotic pseudoaneurysms of the subclavian artery (SA) is rare. Only 3 cases of a combined open and endovascular treatment of true SA aneurysms have been reported. Conventional treatment for SA pseudoaneurysms is invasive thoracic surgery. Ours is a novel approach for mycotic pseudoaneurysm. METHODS: A 72 year-old man with gastric cancer developed vocal cord paralysis because of a mycotic pseudoaneurysm of the right SA, after Hickman line insertion. Because of the close proximity between the pseudoaneurysm at the origin of the SA and the innominate and common carotid arteries, a combined endovascular and open carotid SA bypass was performed. RESULTS: At 1-year follow-up, he recovered well, remained cancer-free, with resolution of the pseudoaneurysm. Both the anastomoses and stents remained widely patent. CONCLUSIONS: This case represents the first reported successful treatment of a mycotic SA pseudoaneurysm through a combined open bypass and covered stenting, with encouraging outcomes at 1-year follow-up.

Surgical treatment of central venous catheter related septic deep venous thrombosis.

OBJECTIVE/BACKGROUND: The aim of this study was to evaluate the clinical features and outcomes of catheter related central venous thrombosis and whether a surgical approach can be an effective treatment modality in selected cases that are refractory to conservative management. METHODS: This was a retrospective review of the 46 consecutive patients who were suspected of having central venous catheter related infected deep venous thrombosis and who met the eligibility criteria. RESULTS: Conservative management achieved clinical improvement in 26 (56.5%) patients and failed in 20 (43.5%), of whom surgical thrombectomy was performed in 13. The remaining seven patients died before surgery could be performed or their clinical condition was too poor. Apart from one case of wound hematoma (7.7%), post-operative complications that related to the surgical procedure were not observed. Patency of the involved vein was re-established in 12 of the 13 (92.3%) surgically treated patients, and clinical improvement was achieved in 11 (84.6%). In particular, the five patients whose blood cultures revealed Candida species exhibited prompt defervescence after surgical thrombectomy. CONCLUSION: Although conservative management is the first therapy of choice in patients with central venous catheter related infected thrombosis, surgical treatment that removes the septic material can be regarded as a last resort in critically ill patients with septic thrombophlebitis that is refractory to conservative management.

Open surgical management of complications from indwelling radial artery catheters.

BACKGROUND: Cannulation of the radial artery is frequently performed for invasive hemodynamic monitoring. Complications arising from indwelling catheters have been described in small case series; however, their surgical management is not well described. Understanding the presentation and management of such complications is imperative to offer optimal treatment, particularly because the radial artery is increasingly accessed for percutaneous coronary interventions. METHODS: We conducted a retrospective review to identify patients who underwent surgical intervention for complications arising from indwelling radial artery catheters from 1997 to 2011. RESULTS: We identified 30 patients who developed complications requiring surgical intervention. These complications were categorized into ischemic and nonischemic, with 15 patients identified in each cohort. All patients presenting with clinical hand or digital ischemia underwent thrombectomy and revascularization. Complications in the nonischemic group included three patients with deep abscesses with concomitant arterial thrombosis, two with deep abscesses alone, and 10 with pseudoaneurysms. Treatment strategy in this group varied with the presenting pathology. Among the entire case series, three patients required reintervention after the initial surgery, all in individuals initially presenting with ischemia who developed recurrent thrombosis of the radial artery. There were no digital or hand amputations in this series. However, the overall in-hospital mortality in these patients was 37%, reflecting the severity of illness in this patient cohort. Three patients who were positive for heparin-induced thrombocytopenia antibody had 100% mortality compared with those who were negative (P = .04, Fisher exact test). In-hospital mortality was higher in patients presenting with initial ischemia than in those with nonischemic complications (53% vs 20%; P = .06). Among 10 patients who presented with pseudoaneurysms, five (50%) were septic at presentation with positive blood cultures, and six (60%) had positive operating room cultures. Staphylococcus aureus was identified as the causative organism in all of these patients. CONCLUSIONS: Complications of radial artery cannulation requiring surgical intervention can represent infectious and ischemic sequelae and have the potential to result in major morbidity, including digital or hand amputation and sepsis, or death. Although surgical treatment is successful and often required in these patients to treat severe hand ischemia, hemorrhage, or vascular infection, these complications tend to occur in critically ill hospitalized patients with an extremely high mortality. This must be taken into consideration when planning surgical intervention in this patient cohort. Finally, radial arterial cannulation sites should not be overlooked when searching for occult septic sources in critically ill patients.

Risk factors for morbidity and mortality in pediatric patients with peritoneal dialysis catheters.

PURPOSE: As peritoneal dialysis (PD) is the preferred long-term dialysis modality in the pediatric population, we sought to identify risk factors for mortality and reoperation. METHODS: A retrospective review of patients undergoing PD catheter insertions at a single center from 1994-2009 was performed. The following variables were evaluated: age (<1 year), comorbidities, omentectomy, concomitant gastrostomy, and laparoscopic technique. Multivariable Cox regressions analyses were used to evaluate patient survival and reoperation-free survival of PD catheters. RESULTS: 207 patients with a median age of 10 years underwent PD insertion. Mortality was 7% with a median follow up of 72 months. Reoperation for malfunction and infection was required in 49% of patients with a median PD catheter survival of 11 months. Reoperation for hernias occurred in 14% of patients. Multivariate Cox regressions analyses identified age <1 year, lack of omentectomy, concomitant gastrostomy, and prematurity as variables significantly associated with higher rates of mortality or reoperation. CONCLUSIONS: In this large study of pediatric patients undergoing PD, higher complication rates were noted in infants less than one year of age. Concomitant gastrostomy was associated with a higher rate of reoperation for infection. Failure to perform omentectomy was associated with a higher rate of catheter failure.

Adjunctive use of the superficial femoral vein for vascular reconstructions.

OBJECTIVE: Although the superficial femoral vein (SFV) is an accepted treatment for aortic graft infections, this conduit also has potential uses in other areas. Herein, we evaluate our experience using the SFV for arterial and venous bypasses and the arteriovenous (AV) fistula for dialysis access. METHODS: Between 1999 and 2011, 42 patients underwent a bypass or a thigh AV fistula using the SFV (31 arterial, four central venous, six AV fistulas, and one common carotid-to-vertebral bypass). Indications for arterial bypass included infected graft (20), critical limb ischemia (nine), and failed bypass (six). Indications for central venous bypass were: superior vena cava syndrome (two), vessel reconstruction due to tumor encasement (one), and central vein occlusion from thoracic outlet syndrome (one). All AV fistulas were created after patients sustained bilateral subclavian vein occlusions from failed upper extremity access. The common carotid-to-vertebral bypass was created due to an occluded vertebral artery with resultant stroke. RESULTS: Kaplan-Meier cumulative patency curves were used. The primary patency rates at 30 days, 1 year, and 3 years were 97.4% (95% confidence interval [CI], 92.41-100), 74.6% (95% CI, 57.89-96.23), and 66.4% (95% CI, 47.06-93.53), respectively. The assisted primary patency rates at 30 days, 1 year, and 3 years were 100% (95% CI, 100-100), 97.1% (95% CI, 91.54-100), and 89% (95% CI, 74.29-100), respectively. Secondary patency rates at 30 days, 1 year, and 3 years were 100% (95% CI, 100-100), 97.1% (95% CI, 91.54-100), and 89% (95% CI, 74.29-100), respectively. Limb salvage rates at 30 days, 1 year, and 3 years were 97.3% (95% CI, 92.21-100), 93.6% (95% CI, 78.35-100), and 93.6% (95% CI, 78.35-100), respectively. Survival rates at 30 days, 1 year, and 3 years were 97.6% (95% CI, 92.95-100), 86% (95% CI, 75.3-98.3), and 86% (95% CI, 75.3-98.3), respectively. Follow-up ranged from 1 month to 8.7 years (mean time, 21 months). Complications occurred in 22 patients (52%) and included wound complications (n = 19; 45.2%); deep vein thrombosis (n = 1; 2.4%); anastomotic breakdown (n = 1; 2.4%); hematoma (n = 4; 9.5%); pulmonary embolism (n = 2; 4.8%); and compartment syndrome (n = 2; 4.8%). CONCLUSIONS: The SFV is a durable conduit for uses beyond aortic reconstruction and should be considered when the great saphenous vein is not available or size match is a concern. However, wound complications remain a problem.

[Treatment of a female patient with sickle-cell anemia during cardiac surgery with cardiopulmonary bypass]. / Tratamiento de una paciente con drepanocitosis homocigota durante la cirugía cardiaca con circulación extracorpórea.

A 17-year-old girl with drepanocytic (sickle-cell) anemia who was being treated with hydroxyurea and periodic blood transfusions through a Hickman-type catheter was admitted for periodic episodes of fever. Blood cultures were positive for methicillin-sensitive Staphylococcus aureus. Massive right atrial thrombosis with pulmonary embolism and bacterial endocarditis were detected by computed tomography. Surgery with a beating heart and cardiopulmonary bypass was undertaken. Drepanocytic anemia in individuals homozygous for hemoglobin S is a rare condition in Spain but we are beginning to see a few cases, in which management during anesthesia will be more complicated. High-risk surgery can be carried out in these patients without adverse events if the anesthesiologist is guided by a complete blood workup and takes precautions during and after surgery to control hydration, oxygenation, temperature, and the acid-base balance.

Evaluation of radiologically implanted central venous port systems explanted due to complications.

PURPOSE: The aim of this study was to evaluate explantations of central venous port systems that were implanted by interventional radiologists in cases where complications demanded the removal of the port device. METHODS: In this retrospective single-center study, explantation rates of central venous port catheter systems (CVPS) associated with complications were investigated over a 10-year period. All CVPS were implanted and explanted in our radiology department's interventional suite. Port catheter dysfunctions were divided into early and late complications, as well as into nonthrombotic and thrombotic events. Indications for implantation and explantation as well as clinical demographics were considered. RESULTS: One hundred and ninety-three CVPS were removed from 182 patients, due to complications. The total indwelling time of all CVPS was 55,132 catheter-days (mean 285.7; range 1-2,704). The most common diagnoses were gastrointestinal cancers 77 (39.9%) and hematological malignancies 32 (16.6%). Bloodstream infections 134 (69.4%) were the most common indication for the explantation procedure. These were followed by catheter-related thrombosis 28 (14.5%), nonthrombotic CVPS dysfunction 18 (9.3%), port pocket infections 9 (4.7%), and others 4 (2.1%). The highest percentages of explantations related to bloodstream infections were observed in patients with malabsorption (81.8%) and hematological malignancies (81.3%). CONCLUSION: Bloodstream infections were the most common cause for port explantation, followed by catheter-related thrombosis. Complication-related explantations were mainly for late-onset complications. Prevention and management strategies should be applied regarding care and usage of port systems to reduce the rate of complication-related explantations.

Surgical treatment of septic jugular thrombophlebitis in nine horses.

OBJECTIVE: To report a technique for surgical treatment of septic jugular thrombophlebitis unresponsive to medical treatment. STUDY DESIGN: Case series. ANIMALS: Horses (n=9) with septic jugular thrombophlebitis unresponsive to medical treatment. METHODS: Jugular vein thrombectomy was performed under standing sedation and local anesthesia. The contents of the affected portion of vein were removed by multiple incisions in the vein, with the incisions left open to drain and heal by second intention. RESULTS: The technique was curative in all instances, although 2 horses required a 2nd procedure. One horse required ligation of the linguofacial vein to control postsurgical hemorrhage. CONCLUSIONS: The technique is an effective surgical treatment for septic jugular thrombophlebitis unresponsive to medical treatment. CLINICAL RELEVANCE: Jugular vein thrombectomy is a straightforward technique, and has minimal postoperative complications. It allows expedient and cost-effective resolution of medically recalcitrant cases of septic jugular thrombophlebitis.

Conservative surgical management of catheter infections in children on peritoneal dialysis.

INTRODUCTION: Major indications for peritoneal dialysis catheter removal include chronic exit-site infection (ESI) or tunnel infection (TI). No consensus on the optimal treatment of these infections in children exists. PATIENTS: During the last 10 years, 13 patients (7 females, mean age 56 months) on peritoneal dialysis were treated for recurrent ESI (N: 4) or TI (N: 9). Staphylococcus aureus (12 patients) and Pseudomonas aeruginosa (1 patient) were isolated. All patients had a double-cuff straight Tenchkoff catheter and underwent the shaving of the external cuff, with a new tunnel tightly adherent to the catheter, and an exit-site in the opposite abdominal region. A mean follow-up of 31 months/catheter demonstrated no recurrence of ESI and TI. DISCUSSION: Little pediatric experience with cuff shaving exists: reported catheter salvage rates are 48-100%. In our experience, good results were obtained by shaving off the external cuff and re-creating a new tunnel, with a different course, strictly adherent to the catheter. This measure seems to guarantee an effective barrier against infections, while obviating the need of the external cuff. CONCLUSIONS: Sometimes, in case of recurrent ESI or TI, the external cuff may facilitate the persistence of bacteria. A conservative surgical treatment offers good results in children.