The Effect of Patient Oral Intake Status on Abdominal Aortic Ultrasound Visualization.

BACKGROUND: The standard abdominal aortic duplex ultrasound protocol requires fasting for 8-12 hours prior to examination in attempt to reduce bowel gas and improve visualization. Such practice results in frequent testing delays and patient non-compliance. The aim of this study was to determine whether fasting improves visualization of the abdominal aorta in patients undergoing duplex ultrasound or influences diagnostic properties. METHODS: This was a prospective, randomized, double-blind imaging trail at a single institution. Ninety patients were randomized to one of three dietary groups, including NPO, clear liquids or control (regular diet). Diagnostic ultrasound examinations were performed by accredited Registered Vascular Technologists who remained blinded to the patients' diet. Sonographers commented on the presence of limited visualization in the study based on their ability to accurately measure aortic diameter. Examination results were randomly assigned to interpreting physicians who were also blinded to the patients' diet. Following interpretation, the reading physician was asked to comment whether they had sufficient information for a conclusive diagnostic interpretation. RESULTS: All ultrasound studies were deemed diagnostic by the interpreting physician regardless of the patients' dietary status. Limited visualization was reported in 19 of the 90 study patients (21.1%) with no significant difference existing between the dietary groups (P = 0.344). The NPO group contained the most patients with studies deemed to have limited visualization. CONCLUSION: Oral intake status did not affect visualization of the abdominal aorta or the rate of diagnostic studies in patients undergoing DUS at a single center. These results suggest that dietary restrictions prior to DUS evaluation of the abdominal aorta is unnecessary.

Emergent carotid endarterectomy versus stenting in acute stroke patients with tandem occlusion.

OBJECTIVE: Acute stroke due to tandem cervical internal carotid artery (ICA) and intracranial large-vessel occlusion (ILVO) has a high rate of morbidity and mortality. The most appropriate treatment strategy for the extracranial culprit lesion remains unclear. In this study, we report our institutional outcomes with two approaches: emergent carotid endarterectomy (CEA) and carotid artery stenting (CAS). METHODS: Patients with tandem ICA-ILVO were identified in a prospective mechanical thrombectomy (MT) database between July 2012 and April 2016. Patients had a concomitant complete ICA origin occlusion and occlusion of the intracranial ICA or M1 or M2 middle cerebral artery segment. Baseline characteristics, procedural data, and treatment times were reviewed. End points included good recanalization of both ICA and ILVO, symptomatic intracerebral hemorrhage (defined by clinical decline of >4 points on the National Institutes of Health Stroke Scale), and functional outcome at 90 days. RESULTS: Forty-five patients had tandem ICA-ILVO occlusion; 27 patients underwent emergent CAS and 12 patients underwent emergent CEA after MT. Successful Thrombolysis in Cerebral Infarction grade 2B/3 recanalization was achieved in 92% of the CEA and 96% of the CAS patients (P = .53). Three CAS patients (11%) and none of the CEA patients had symptomatic intracerebral hemorrhage (P = .54). At 90 days, 75% (9/12) of the CEA patients were functionally independent compared with 70% (19/27) in the CAS group (P = 1.0). No deaths were noted in the CEA group compared with five (18.5%) in the CAS arm (P = .30). CONCLUSIONS: Our study indicates that early recanalization with MT followed by emergent CEA is safe and feasible, which suggests that both CAS and CEA should be considered in the emergent treatment of patients with tandem occlusion.

Carotid artery pseudoaneurysm as a complication of carotid artery stenting.

Carotid artery stenting (CAS) has been adopted more in the treatment of carotid artery stenosis recently. The vast majority of studies about this procedure have concentrated mainly on the short- and long-term clinical complications, that is, stroke, myocardial infarction, and restenosis. However, mechanical complications including both stent fracture and carotid pseudoaneurysm are under-reported. In the present report, we present a patient with a common carotid artery psuedoaneurysm as a complication of CAS.

A single center experience with retrievable IVC filters.

OBJECTIVE: To evaluate retrievable IVC filters in our institution and assess their retrieval following a well-structured follow up program. DESIGN: Retrospective cohort study. MATERIALS: The medical records of patients implanted with retrievable IVC filters were reviewed. METHODS: All retrievable filter insertions between July 2007 and August 2011 at our institution were reviewed. Data was analyzed for age, gender, indication, complications, retrieval rate, and brand of filter inserted. Statistical analysis was done using SPSS software v19. Chi-square was used to compare discrete data and t-test for continuous data. P < 0.05 was significant. RESULTS: A total of 484 patients were reviewed of which 258 (53.1%) had a complete medical record. And 96 (37.2%) filters were placed as permanent at the time of insertion. An additional 40 (15.5%) filters were converted to permanent (total permanent filters 136; 52.7%). Death was reported in 26 (10%) patients and 96 (37.2%) out of the remaining 232 patients presented for potential retrieval. Also, 73 (28.2%) had an attempt to retrieve the filters, 69 (94.5%) were successful and 4 (5.4%) failed to retrieve. The remaining 23 (8.9%) patients declined retrieval. Filters studied include Celect (38%), Bard (31.4%), Option (26.2%), Tulip (4.1%), and Recovery (0.2%). Bard was more commonly used as a retrievable filter (80.9%). Retrieval on the first attempt was 90.4% (n = 66) successful. Of the remaining seven filters, three were successfully retrieved on a second attempt, and four failed to retrieve due to filter tilt. The success rates of retrieval for Celect and Tulip were significantly lower than for Bard (p = 0.04 and 0.023, respectively). CONCLUSION: Our study showed that a variety of IVC filters can be retrieved successfully with minimal complication rates. In more than half of our patients, IVC filters were used as permanent. Failure of retrieval was most frequently due to filter tilting.

Internal jugular vein hemangioma.

Primary tumors of the major body veins arising intraluminally are rare clinical entities. As such, few cases have been reported in the literature. As a primary tumor, hemangiomas arising in the internal jugular vein are extremely rare, while those arising in the external jugular vein are only slightly more common. We present a case of an internal jugular vein hemangioma that was incidentally discovered during an ultrasound examination performed for the evaluation of the internal carotid arteries. We believe that this is the second case of internal jugular vein hemangioma reported in the English literature.

Medical scribes.

Medical scribes and electronic health records (EHRs) are increasingly being introduced into ambulatory clinics with variable outcomes. Characteristics of a successful implementation of medical scribes are described. Tips for optimization of the composition and presentation of the EHR as well as medical processes associated with medical documentation are presented.

Interface pressure changes under compression bandages during period of wearing.

BACKGROUND: The aim of the present study was to investigate the changes in pressure over time under three different compression bandages and compare the temporal patterns of pressure changes among them. METHODS: The 4-hour changes in interface pressure were investigated in 10 volunteers with no venous disease or leg swelling. In 20 patients with venous ulcers, the change in interface pressure was measured after 4 hours, 1 day, and 7 days of bandage wearing. The three bandages tested were the Smart Sleeve compression system (SSB; Carolon, Rural Hall, NC), Coban 2 (C2; 3M, St Paul, Minn), and Profore Lite (PL; Smith & Nephew, London, United Kingdom). Pressure measurements were performed using the PicoPress transducer (Microlab, Padua, Italy) and the Juzo Pressure Monitor (Juzo, Cuyahoga Falls, Ohio). RESULTS: In the 10 volunteers, the mean pressure loss during the first 4 hours under the SSB, C2, and PL were 4.5, 3.7, and 6.6 mm Hg, respectively. No significant differences were seen in the pressure loss among the three bandages, whether in the supine (P = .59) or standing (P = .47) position. In the 20 patients with venous ulcers, the pressure had decreased gradually over 7 days under the C2 bandages. For the SSB and PL bandages, however, the interface pressure was relatively stable during the first day but decreased significantly afterward. The mean pressure loss during the 7 days was 4.7, 7.7, and 8.6 mm Hg for the SSB, PL, and C2, respectively (P = .017). Only the SSB maintained a desirable mean pressure >30.0 mm Hg on the seventh day in the patients with venous ulcers. CONCLUSIONS: The interface pressure had decreased over time under all three studied bandages. However, the temporal pattern of the pressure changes varied among the different bandages. Therefore, monitoring the interface pressure, allowing for adjustment or changes of the bandage at an accurate point, is essential to maintain a desirable interface pressure during compression therapy.

Iliofemoral venous thrombosis from external compression by a vesical diverticulum.

Twenty six percent to 47% of venous thromboembolisms (VTE) are classified as idiopathic. Deep venous thrombosis (DVT) due to external compression of the venous system by various lesions has been reported in the literature. Identification of such lesions may obviate the need for prolonged anticoagulation and prevent recurrence. An important step in the evaluation of cases with iliofemoral thrombosis is to obtain computed tomography (CT) of the abdomen and pelvis to identify any potential pathology. We report a case of acute unilateral iliofemoral DVT caused by external compression from a vesical diverticulum. The CT scan played a crucial role in the diagnosis and guided management.

Complications related to inferior vena cava filters: a single-center experience.

We reviewed our experience with the different types of inferior vena cava (IVC) filters used over 4 years for the incidence of complications and correlated this with the type of filter used. This is a retrospective study involving chart reviews of all the patients who received IVC filters placed between January 2002 and January 2006. Data related to indications for filter insertion and the incidence of early (30 days) and late complications related to the filter insertion were collected. Complications were correlated to the type of filter and the indication for insertion. Statistical analysis was done using Fisher's exact test, and p<0.05 was considered significant. During this period 400 filters were inserted. There were 199 males (49.7%) and 201 females (50.25%). The mean patient age was 61 years (range 17-86). Filters used included TrapEase in 224 (56%), Greenfield filter in 95 (23.8%), Gunther-Tulip in 42 (10.5%), Bard recovery nitinol (all first-generation) in 34 (8.5%), and Simon Nitinol filter in five (1.2%). The indications for IVC filter insertion included acute venous thromboembolism (VTE) event in 273 patients (68.25%) and pulmonary embolism (PE) prophylaxis in 127 (31.75%) patients. In the group with VTE, 59 (21.6%) had contraindication for anticoagulation and 34 (12.5%) had hypercoagulable/malignant conditions. In the 127 patients who received the filter for PE prophylaxis in the absence of VTE, 107 (84.3%) had fractures, 43 (33.9%) had head injury, 32 (25.2%) had multiple trauma, and 15 (11.8%) had paralysis. Sixteen (12.6%) of the prophylaxis patients had IVC filter insertion prior to an elective surgical procedure. Complications in the form of hematoma at the site of filter insertion occurred in four (1%) patients, ipsilateral limb deep vein thrombosis in 15 (3.8%) patients, migration/tilt of filter in six (1.5%) patients, PE in six (1.5%) patients, and IVC thrombosis in 19 (4.75%) patients. Migration/tilt was higher in Bard filters compared to other filters, individually (p<0.004) and as a group (11.8% vs. 0.55%, p<0.0005). All other complication had a comparable incidence in all filters. However, in the group of patients (n=34) who had hypercoagulable/malignant conditions, the incidence of IVC thrombosis was higher with TrapEase filters compared to all other filters as a group (25% vs. 0%, p<0.05). In conclusion, IVC filters are frequently used for prophylaxis in the absence of VTE conditions. Complications are relatively low. All types of filters used in this study had comparable complications with the exception of the Bard filter, which had a higher incidence of tilt, and the TrapEase filter, which had a higher incidence of IVC thrombosis, in patients with hypercoagulable/malignant conditions.

Complications secondary to the Bard retrievable filter: a case report.

Recent trials have demonstrated the efficacy of short-term insertion of inferior vena cava filters in the treatment and prophylaxis of venous thromboembolism certain populations, especially those with a reversible contraindication to anticoagulation. This has widened the use of retrievable filters in the hope of avoiding the long-term complications of permanent filters. However, no trials have demonstrated complications for each individual retrievable filter; and therefore, the decision for insertion of caval filter should be thoroughly studied and the benefit clearly determined. We discuss our experience with complications that we have encountered during retrieval of the Bard recovery filter in two patients.

Outcome after thoracic aortic injury: experience in a level-1 trauma center.

Traumatic rupture of the thoracic aorta is a potentially fatal injury that leads to death in 75-90% of cases at the time of injury. In this report, we present our experience with traumatic thoracic aortic injury and compare the outcome in patients with respect to their hemodynamic stability at presentation and the timing of surgical repair. We performed a retrospective data analysis of the medical records of 30 patients who had sustained a traumatic rupture of the thoracic aorta during the period from January 1, 2000 to October 30, 2005. The demographic data, mechanism of injury, modality of diagnosis, location of injury, other associated injuries, hemodynamic stability at presentation, response to resuscitation, timing of aortic repair, as well as the resultant morbidities and mortalities were reviewed. Traumatic rupture of the thoracic aorta was diagnosed in 30 patients. The injury was located in the ascending aorta in two patients, in the aortic isthmus in 25 patients, and in the descending aorta (distal to the isthmus) in three patients. Associated injuries included head injury (50%), C spine (23.3%), lung injury (80%), and visceral (63%) and extremity (60%) injury. Seven patients (23%) were pronounced dead on arrival to the emergency room, 14 patients (47%) were hemodynamically unstable upon arrival, and nine patients (30%) were hemodynamically stable. In the unstable group, two patients (14%) expired before operative repair, 11 patients (79%) underwent emergent repair of the thoracic aorta resulting in 46% mortality, and one patient (7%) underwent delayed repair after initial stabilization with a splenectomy for a splenic laceration. In the stable group, three patients (33%) underwent early (within 24 hr) aortic surgery, while repair was delayed in six (67%). The mean duration of time spent prior to delayed repair was 20.85 days (range 2-53, median = 25). There was no mortality in this group. Acute traumatic thoracic aortic rupture remains a highly fatal condition. Hemodynamic instability remains the main mortality risk factor. Delayed repair is safe and is not associated with increased risk of aortic rupture in hemodynamically stable patients.

Patient variables impacting hospital costs from 2008 to 2010.

BACKGROUND: Studying the variables associated with the increased costs of health care provides valuable insight. METHODS: A review and analysis of the pertinent variables and information collected for 118.3 million hospital admissions recorded as Nationwide Inpatient Samples database was done for the years 2008 to 2010. We used hospital charges as an approximation of costs in the analysis of the patient variables and other factors contributing to hospital costs. RESULTS: The top 5 factors with the most impact on charges were diagnostic category, length of stay, number of procedures, major operating room procedures, and ownership of the hospital. CONCLUSION: The top 5 factors with the most impact on charges were length of stay, number of procedures, major diagnostic category, major operating room procedures, and ownership of the hospital.

Ligation of superior mesenteric vein and portal to splenic vein anastomosis after superior mesenteric-portal vein confluence resection during pancreaticoduodenectomy - Case report.

UNLABELLED: 62 year old Caucasian female with pancreatic head mass abutting the superior mesenteric vein (SMV) presented with fine needle aspiration biopsy confirmed diagnosis of ductal adenocarcinoma. CT scan showed near complete obstruction of portal vein and large SMV collateral development. After 3 months of neoadjuvant therapy, her portal vein flow improved significantly, SMV collateral circulation was diminished. Pancreaticoduodenectomy (PD) and superior mesenteric portal vein (SMPV) confluence resection were performed; A saphenous vein interposition graft thrombosed immediately. The splenic vein remnant was distended and adjacent to the stump of the portal vein. Harvesting an internal jugular vein graft required extra time and using a synthetic graft posed a risk of graft thrombosis or infection. As a result, we chose to perform a direct anastomosis of the portal and splenic vein in a desperate situation. The anastomosis decompressed the mesenteric venous system, so we then ligated the SMV. The patient had an uneventful postoperative course, except transient ascites. She redeveloped ascites more than one year later. At that time a PET scan showed bilateral lung and right femur metastatic disease. She expired 15 months after PD. CONCLUSION: The lessons we learned are (1) Before SMPV confluence resection, internal jugular vein graft should be ready for reconstruction. (2) Synthetic graft is an alternative for internal jugular vein graft. (3) Direct portal vein to SMV anastomosis can be achieved by mobilizing liver. (4) It is possible that venous collaterals secondary to SMV tumor obstruction may have allowed this patient's post-operative survival.

Fractured internal carotid artery stent.

Carotid artery stenting is gaining wider acceptance as an alternative option in the treatment of carotid artery stenosis. Conventional complications such as stroke and recurrent in-stent restenosis are well documented in the literature. However, we believe that carotid stent complications are underreported. The carotid artery segment has features that are relatively smilar to the femoropopliteal segment with respect to forces affecting the stented segment, which can contribute to stent complications such as fracture. In this article, we present a case of internal carotid artery stent fracture and thrombus formation after the patient was exposed to direct trauma to the chest and neck.

Aortic arch abnormality in a patient with Klippel-Feil syndrome.

We present a case of a 43-year-old female with headaches, progressive paresthesias of the upper extremities, and vertigo. Ultrasonography could not visualize the left internal carotid artery (ICA). Magnetic resonance imaging (MRI) showed complete fusion of the C5, C6, and C7 levels, representing Klippel-Feil deformity. Angiography showed a unique abnormality of the aortic arch with complete absence of the left ICA. An embryologic defect associated with this type of abnormality is proposed, with defects of development of the third aortic arch and the aortic sac secondarily.