A Patient-Tailored Approach to Management of Acute Limb Ischemia in Patients with COVID-19: A Case Series.

BACKGROUND Coronavirus disease 2019 (COVID-19) has a tremendous impact on the respiratory tract. In severe COVID-19 infections, patients may experience shock and multiple organ failure. We described 4 cases of severe arterial thrombosis induced by COVID-19 with and without other stressors and their responses to treatment measures. CASE REPORT In Case 1, a 61-year-old man was hospitalized for COVID-19 pneumonia 2 weeks prior to the presentation of acute upper-limb ischemia after intravenous forearm line insertion. He was classified as IIB and thus underwent emergency thrombectomy followed by 3 months of enoxaparin. Case 2 was a 41-year-old female patient with granulomatosis who was admitted to the Intensive Care Unit due to COVID-19 pneumonia and developed acute upper-limb ischemia. A medical approach using therapeutic heparin was used. Case 3 was a 65-year-old man who was admitted due to COVID-19-related pneumonia and was otherwise medically and surgically free. We assessed and managed a new onset of the lower-limb IIB acute limb ischemia (ALI). Case 4 was a patient with the first COVID-19 presentation of ALI, which was managed accordingly. CONCLUSIONS The development of a thrombotic event in patients with COVID-19 was previously reported. Moreover, different management options and outcomes have been reported in the literature. Therefore, careful planning is needed for procedures such as cannulation or central line insertion to prevent such events. In addition, short-term anticoagulation therapy might be of clinical benefit when planning a procedure or if the patient exhibits minor arterial complications.

Review of Renal Artery Stenosis and Hypertension: Diagnosis, Management, and Recent Randomized Control Trials.

Renal artery stenosis is one of the most common causes of secondary hypertension (HTN). Renal artery stenosis-induced HTN can occur in the presence of unilateral or bilateral narrowing and a solitary kidney with stenotic artery, which may subsequently lead to renal insufficiency (e.g., ischemic kidney disease) or pulmonary edema. Renal artery stenosis can be diagnosed using multiple modalities, including Doppler ultrasound, computed tomography angiography, magnetic resonance angiography, or selective angiogram. Although atherosclerotic renal artery stenosis management in patients with HTN has been greatly controversial, it is inevitable in the treatment of some selected cases. These cases can be treated by either percutaneous angioplasty (with or without stenting) or less common, open surgical approach revascularization, both of which have excellent primary patency rates. Generally, several trials on renal artery angioplasty or stenting in patients with atherosclerotic disease have shown that the long-term benefits in terms of blood pressure control and renal function over pharmacological management is not substantial. Furthermore, studies could not demonstrate a prolongation of event-free survival after renal vascularization. Moreover, endovascular procedures have substantial risks. Careful patient selection is required when considering revascularization, for including those with refractory HTN or progressive renal failure, to maximize the potential benefits. This paper discusses the epidemiology of atherosclerotic renal artery stenosis and its clinical presentation, diagnosis, treatment, prognosis, and future perspectives.

Thyroid surgery in 103 children in a single institution from 2000-2014.

BACKGROUND: Data on thyroid surgery in children are scarce. OBJECTIVE: Analyze outcome data on thyroid surgery in a pediatric population. DESIGN: Medical record review. SETTING: Tertiary health care institution. PATIENTS AND METHODS: We collected demographic and clinical data on patients 18 years or younger who had thyroid surgery in the period 2000 to 2014. Descriptive data are presented. MAIN OUTCOME MEASURES: Indications for thyroidectomy, thyroid pathology, complications, length of stay, and radioactive iodine treatment and recurrences. SAMPLE SIZE: 103. RESULTS: Of 103 patients who underwent 112 thyroidectomy procedures, 80 (78%) were females and the mean age at operation was 13.2 years. and 17 (16%) were associated with multiple endocrine neoplasia type 2. There was no history of radiation exposure. Eighty-one patients (78%) had fine needle aspiration (FNA) which correlated with the final histopathology in 94% of cases. Sixty-six patients (64%) had malignant cancer (61 papillary), 44 (74.6%) of 59 patients who had neck dissection had lymph node metastasis and 7 (11%) had distant metastases to the lung. Procedures included total thyroidectomy (50%), hemithyroidectomy (17%), completion (31%), and subtotal thyroidectomy (2%). Twenty-three patients (22%) developed hypocalcemia (3 permanent) and 6 (5.8%) had unilateral recurrent laryngeal nerve injury (3 permanent). Patients were followed up for a mean duration of 71.7 months (median 60 months). Of 66 patients with thyroid cancer, 43 (65%) received radioactive iodine, and 10 (15%) had recurrence. CONCLUSION: Malignancy is the commonest indication for thyroid surgery in children and FNA is highly diagnostic. Hypocalcemia and recurrent laryngeal nerve injury are significant complications. The recurrence rate in thyroid cancer is 15%. LIMITATIONS: Retrospective. CONFLICT OF INTEREST: None.

Endothermal heat-induced thrombosis after endovenous laser ablation: A single-center experience.

Lower limb varicose veins are a common vascular disorder producing pain and disability when truncal vein reflux is present. Endovenous laser ablation (EVLA) of the great saphenous vein (GSV) is a safe and effective method for treating this condition. An unintended complication of this procedure is endothermal heat-induced thrombosis (EHIT) of common femoral vein. A retrospective outcomes analysis of patients who underwent EVLA of the GSV at King Khalid University Hospital from June 2006 to November 2018 was conducted to identify the risks factors and incidence of EHIT. Patients were assessed by clinical examination and duplex ultrasound imaging after the EVLA, and patient demographic characteristics and procedural factors predictive of EHIT were determined. Following EVLA, 11,070 duplex ultrasound examinations were performed for 1,230 limbs, and EHIT was detected in 65 (5.3%) limbs in 60 (6.8%) patients. Essentially all EHIT cases were detected in the first week (n = 63; 96.9%) and clot regression occurred over a period of 1-4 weeks. There were no significant differences in patient demographic characteristics or procedural factors between the EHIT and non-EHIT groups, except for the percentage of women (86% v 73%; P = .02), maximum GSV diameter (6.7 ± 2.7 mm v 6.0 ± 2.1 mm; P = .04), and percentage of patients with a competent saphenofemoral junction (41% v 37%; P < .001). EVLA is a safe treatment for great saphenous vein reflux, but EHIT can occur and was associated with female sex, large maximum GSV diameter, and competent saphenofemoral junction. Venous duplex imaging after EVLA is recommended because EHIT is asymptomatic in most patients.