Arterial protocol including prophylactic distal perfusion catheter decreases limb ischemia complications in patients undergoing extracorporeal membrane oxygenation.

OBJECTIVE: Venoarterial extracorporeal membrane oxygenation (ECMO) is a salvage therapy in patients with severe cardiopulmonary failure. Owing to the large size of the cannulas inserted via the femoral vessels (≤24-F) required for adequate oxygenation, this procedure could result in significant limb ischemic complications (10%-70%). This study evaluates the results of a distal limb perfusion arterial protocol designed to reduce associated complications. METHODS: We conducted a retrospective institutional review board-approved review of consecutive patients requiring ECMO via femoral cannulation (July 2010-January 2015). To prevent arterial ischemia, a distal perfusion catheter (DPC) was placed antegrade into the superficial femoral artery and connected to the ECMO circuit. Limb perfusion was monitored via near-infrared spectroscopy (NIRS) placed on both calves. Decannulation involved open repair, patch angioplasty, and femoral thrombectomy as needed. RESULTS: A total of 91 patients were placed on ECMO via femoral arterial cannula (16-F to 24-F) for a mean duration of 9 days (range, 1-40 days). A percutaneous DPC was inserted prophylactically at the time of cannulation in 55 of 91 patients, without subsequent ischemia. Of the remaining 36 patients without initial DPC placement, 12 (33% without DPC) developed ipsilateral limb ischemia related to arterial insufficiency, as detected by NIRS and clinical findings. In these patients, the placement of a DPC (n = 7) with or without a fasciotomy, or with a fasciotomy alone (n = 4), resulted in limb salvage; only one patient required subsequent amputation. After decannulation (n = 7), no patients had further evidence of limb ischemia. Risk factors for the development of limb ischemia identified by categorical analysis included lack of DPC at time of cannulation and ECMO cannula size of less than 20-Fr. There was a trend toward younger patient age. Overall ECMO survival rate was 42%, whereas survival in patients with limb ischemia was only 25%. CONCLUSIONS: Limb ischemia complications from ECMO may be decreased by prophylactic placement of an antegrade DPC. Without DPC, continuous monitoring using NIRS may identify limb ischemia, which can be treated subsequently with DPC and or fasciotomy.

Median Arcuate Ligament Syndrome-Review of This Rare Disease.

IMPORTANCE: Median arcuate ligament (MAL) syndrome is a rare disease resulting from compression of the celiac axis by fibrous attachments of the diaphragmatic crura, the median arcuate ligament. Diagnostic workup and therapeutic intervention can be challenging. OBJECTIVE: To review the literature to define an algorithm for accurate diagnosis and successful treatment for patients with MAL syndrome. EVIDENCE REVIEW: A search of PubMed (1995-September 28, 2015) was conducted, using the key terms median arcuate ligament syndrome and celiac artery compression syndrome. FINDINGS: Typically a diagnosis of exclusion, MAL syndrome involves a vague constellation of symptoms including epigastric pain, postprandial pain, nausea, vomiting, and weight loss. Extrinsic compression of the vasculature and surrounding neural ganglion has been implicated as the cause of these symptoms. Multiple imaging techniques can be used to demonstrate celiac artery compression by the MAL including mesenteric duplex ultrasonography, computed tomography angiography, magnetic resonance angiography, gastric tonometry, and mesenteric arteriography. Surgical intervention involves open, laparoscopic, or robotic ligament release; celiac ganglionectomy; and celiac artery revascularization. There remains a limited role for angioplasty because this intervention does not address the underlying extrinsic compression resulting in symptoms, although angioplasty with stenting may be used in recalcitrant cases. CONCLUSIONS AND RELEVANCE: Median arcuate ligament syndrome is rare, and as a diagnosis of exclusion, diagnosis and treatment paradigms can be unclear. Based on previously published studies, symptom relief can be achieved with a variety of interventions including celiac ganglionectomy as well as open, laparoscopic, or robotic intervention.

Contained rupture of a pseudoaneurysm of the descending thoracic aorta related to remnant outflow graft of left ventricular assist device after heart transplantation.

The Jarvik 2000 left ventricular assist device is inserted via a left thoracotomy with the outflow graft anastomosed to the descending thoracic aorta. Removal of the device during heart transplantation involves division of the outflow graft, resulting in a retained remnant. We describe the first reported case of a mycotic pseudoaneurysm of the descending thoracic aorta related to the remnant of a left ventricular assist device outflow graft in an immunosuppressed heart recipient complicated with systemic Pseudomonas infection. The pseudoaneurysm was temporarily treated with endovascular stent grafting followed by delayed thoracotomy, pseudoaneurysm excision, and placement of an aortic interposition graft using an aortic allograft.

Management of infected caval filter with simultaneous aortic pseudoaneurysm and retroperitoneal perforation: a case report and literature review.

Inferior vena cava (IVC) filters have been reported to have complication rates up to 35%. Penetration of surrounding retroperitoneal structures is an uncommon, but potentially serious, complication, with several reports in the literature. We present a unique case of a 34-year-old intravenous drug user with infected IVC filter struts penetrating multiple structures simultaneously. Definitive operative management was necessary for removal of filter struts from the aorta, the second part of the duodenum and the iliopsoas muscle. Drainage and debridement of an associated iliopsoas abscess was performed, followed by aortic and caval reconstruction.

Is balloon angioplasty of peri-anastomotic stenoses of failing peripheral arterial bypasses worthwhile?

INTRODUCTION: Surgical revision of failing peripheral arterial bypass grafts has generally been shown to provide superior patency rates compared to balloon angioplasty. We analyzed whether balloon angioplasty, specifically of peri-anastomotic stenoses (PAS), provided acceptable patency rates, because surgery for these lesions is more difficult and is likely associated with higher complication rates compared to surgical revision of stenoses in the body of a graft. METHODS: This is a retrospective review of PAS balloon angioplasties performed at a single institution between January 1, 1999, and September 1, 2005. We report ''primary site patency'' as a stenosis treated by balloon angioplasty, ''revised primary site patency'' as a stenosis treated by repeat balloon angioplasty, and ''secondary site patency'' as an angioplastied stenosis treated surgically or when the graft thrombosed and was revised surgically. All procedures were performed in an endovascular operating room based on duplex scan findings suggesting a significant stenosis. RESULTS: 48 PAS in 33 autologous vein and 15 prosthetic grafts were treated by balloon angioplasty in 42 patients. Mean follow-up was 12 months (range, 1-49 months). Interventions were performed on 22 femoropopliteal grafts (11 proximal, 11 distal), 20 femorotibial grafts (5 proximal, 15 distal), 2 axillofemoral grafts (2 proximal anastomoses), 2 popliteal-pedal grafts (1 proximal, 1 distal), and 1 common iliac-femoral graft (proximal). Life-table analysis revealed 2-year primary, assisted primary, and secondary patency rates of 38%, 58%, and 84%, respectively. No major complications occurred with any endovascular intervention. CONCLUSION: Balloon angioplasty of PAS resulted in acceptable 2-year assisted primary patency rate of almost 60%. Endovascular intervention avoided repeat incisions in scarred groins, higher rates of nerve injury and infection, significant blood loss, and longer length of hospital stays. We recommend that balloon angioplasty of PAS be attempted before resorting to surgical intervention, especially in cases of hostile anastomotic wounds.

Endovascular repair of symptomatic external carotid artery stenosis.

The treatment of external carotid artery stenosis has been described with a variety of operative interventions. We present a patient who presented with amaurosis fugax and a critical left external carotid artery stenosis with known left internal carotid artery occlusion. We treated this stenosis with angioplasty and stenting rather than endarterectomy. Our patient did well and had no complications from the procedure. Endovascular repair of symptomatic external carotid artery stenosis provides an alternative treatment method to conventional endarterectomy for patients with high surgical risk.

Ductus arteriosus aneurysm in an adult patient presenting with hoarseness.

Aneurysm of the ductus arteriosus is a rare diagnosis, with most cases found in the pediatric population. The unusual adult cases reported in the literature have been associated with high morbidity and a surgical repair has been recommended. We report a case of a 60-year-old man who presented with hoarseness secondary to a ductus arteriosus aneurysm and underwent a repair of this abnormality via a left posterolateral thoracotomy utilizing partial cardiopulmonary bypass.