Managing Venous Thromboembolic Disease On-Call.

Managing venous thromboembolic disease on-call requires the interventional radiologist consider not only potential risk and benefit to the patient but also available resources in the IR suite as well as throughout the hospital, such as intensive care monitoring during treatment. We demonstrate how our practice manages these on-call cases ranging from deep venous thrombosis to acute pulmonary embolism and decide which patients need emergent treatment and which can undergo delayed intervention during working hours. In all cases, an adequate preprocedural clinical assessment is crucial.

Technique for Percutaneous Fluoroscopically Guided G-Tube Placement in a High-BMI Patient.

Enteral feeding is still the preferred method of nutritional support even in patients with excessive body mass index. Often, this mass poses a hindrance in performing routine procedures. We present a case describing the technique used to safely place a fluoroscopically guided G-tube in a patient with a significant nutritional deficit after repair of a ruptured thoracic aneurysm. Her admission weight was in excess of 180 Kg. However, protracted respiratory insufficiency and mechanical ventilation prolonged her hospital course. The G-tube was successfully placed using a fluoroscopically guided technique. The advantages of such an approach are discussed.

Management of an unusual iliac fossa venous plexus.

Symptomatic iliac fossa and suprapubic varicosities are uncommon presentations in adults. Such presentations often point to acquired obstructive process to pelvic outflow or to the progression of venous insufficiency and reflux in the pelvic and gonadal veins. Less frequently, venous anomalies of the renal veins or IVC might be implicated. Furthermore, late presentations of congenital or acquired developmental abnormalities might become manifest. As this case illustrates, a thorough understanding of the underlying pathologic process and the anatomical derangement must be sought before any treatment is instituted. Unnecessary extirpation of these varicosities would simply have removed vital physiologic cross-pelvic collateral circulation from the lower extremity in the face of chronic iliac vein occlusion.

Percutaneous repair of a disrupted left renal artery after rapid stabilization.

Fortunately, acute renal artery injuries occur infrequently in blunt trauma patients. Renal salvage in the multi-trauma patient is a daunting task. If after judicious consideration, intervention is warranted, then expeditious repair should follow. Rapid control of exanguinating injuries should be accomplished and the patient stabilized for further intervention - surgical or endovascular. We present the case of a patent who presented with left pneumothorax, multiple bilateral rib, scapula, long bone fractures, hypotension, hemoperitoneum, non perfusion of the left kidney, and a shattered spleen. She underwent emergent splenectomy and stabilization of her pressure. The left renal artery was evaluated and repaired with a covered stent. This approach might be beneficial in highly selected patients with favorable physiologic and anatomical presentations.

Partial splenic embolization for refractory thrombocytopenia.

When the platelet count falls below 20×10(9)/L, the risk of spontaneous life threatening hemorrhage is concerning for both physician and patient. When medical management fails, splenectomy is often used to manage the severe thrombocytopenia before spontaneous, life-threatening gastrointestinal or intracranial bleeding occurs. We present the non surgical management of such a patient with refractory sever thrombocytopenia who refused surgical intervention. She underwent partial splenic embolic therapy with 500-700µ particles. Her platelet count spontaneous recovered from less than 20×10(9)/L to normal range. Her counts remained in normal range after discharge home. Further study is needed to determine the most appropriate role for embolization in patients who are refractory to medical management and those with chronically low platelet counts requiring frequent plate transfusions for invasive procedures.

Considerations in catheter retrieval from the arterial system.

Catheter-based techniques have become commonplace in the diagnosis and treatment of cardiovascular disease. Despite the significant improvements in materials and techniques, catheter separation or fracture may occur and result in catheter embolization or intravascular retention. We present such an occurrence during antegrade access to the common femoral artery. Although the sheared catheter was visualized fluoroscopically, attempts at percutaneous recovery were futile. Our findings at exploration confirmed total intravascular retention and impaction of the catheter. Practitioners should recognize this problem and avoid the dangers associated with percutaneous recovery.

Is bilateral protected specimen brush sampling necessary for the accurate diagnosis of ventilator-associated pneumonia?

BACKGROUND: Clinical acumen alone is unreliable in establishing a diagnosis of ventilator-associated pneumonia (VAP) and controversy exists over which diagnostic tools should be utilized to confirm a clinical suspicion of VAP. The purpose of this study was to determine the reliability of blind protected specimen brush (PSB) sampling in the diagnosis of VAP and if bilateral PSB sampling is necessary. METHODS: Prospective study comparing blind PSB sampling with bronchoscopic directed PSB sampling in thirty-four consecutive SICU patients with a clinical suspicion of VAP. All patients underwent blind PSB sampling followed by bronchoscopic directed contralateral PSB sampling. RESULTS: Twenty-four of 34 patients (71%) were diagnosed to have VAP. The concordance rate between blind and directed PSB samples was 53% (18/34). When blind PSB was positive (15/34), the contralateral sample yielded a different microorganism in three patients (9%). When blind PSB was negative (19/34), infection was present in the contralateral lung in nine patients (26%). Blind PSB sampling alone was inaccurate in 35% of patients. CONCLUSIONS: The low concordance between blind and directed PSB suggests the need to sample both lung fields. Bilateral PSB sampling can identify unsuspected pathogenic microorganisms in the contralateral lung.

Unusual complications of long-term percutaneous gastrostomy tubes.

Percutaneous endoscopic gastrostomy (PEG) has been popular since it was introduced in 1980. Gastrostomy tubes left in place for long periods often result in unusual complications. Complications may also result from simply replacing a long-term indwelling tube. Five patients who had gastrostomy tubes in place for as long as 4 years are presented and their complications reviewed. Various methods used in treating these complications are discussed, and suggestions for their prevention are given. Gastrointestinal erosion and jejunal perforation following migration of the gastrostomy tube, persistent abdominal wall sinus tracts, and separation of the flange head with small bowel obstruction were encountered. Reinsertion of a gastrostomy tube through a tract prior to adequate maturation was also noted to lead to complications. Complications may result from gastrostomy tubes left in place for extended periods of time and during replacement procedures. Awareness of such complications along with education of caregivers and timely intervention by the endoscopist may prevent such occurrences. In some cases one can only hope to minimize morbidity.

Squamous cell carcinoma at herniorrhaphy and unilateral renal agenesis.

Unilateral renal agenesis occurs infrequently. However, it has been associated with malignancies at multiple primary sites, anomalies of the genitourinary system, and supernumerary limbs. We present the case of a 60-year-old man with an incarcerated left inguinal hernia and renal insufficiency. At herniorrhaphy, he had squamous cell carcinoma in the hernia sac. A postoperative evaluation revealed unilateral renal agenesis, stage IV squamous cell carcinoma of the urinary bladder, and urolithiasis. The clinician should consider the genitourinary system as a primary site when patients present with the unusual finding of squamous cell carcinoma in the abdominal cavity and unilateral renal agenesis.

Peroneal-plantar artery bypass: a prone approach.

The potential space behind the distal tibia and ventral to the Achilles' tendon provides a route for bypass grafts to the plantar artery. Grafts may follow the communicating branch of the distal peroneal artery to reach the medial aspect of the foot. A prone approach for distal bypasses from the peroneal artery may facilitate exposure, conserve scarce venous conduit, and avoid scarred or infected sites. This peroneal-plantar bypass route has not been described previously. This technique was successfully used in a patient with diabetes mellitus, recurrent foot ischemia, infection, and limited venous conduit after a failed femorotibial bypass.

Venous claudication in a child with thrombophilia.

Deep venous thrombosis (DVT) rarely occurs in active children. Its presence usually suggests an inherited or acquired hypercoagulable state. Occasionally mechanical obstruction may be the inciting factor in this process. Initial management usually consists of sequential heparin and warfarin anticoagulation. We present the management of DVT in an adolescent girl with elevated levels of C-reactive protein and lupus anticoagulant. Venous claudication and severe lower-extremity swelling on ambulation complicated her course. After more than 2 weeks of conservative therapy with anticoagulation thrombolytic therapy was instituted. This was terminated early because of mild hematuria. However, follow-up duplex scan at 2 years has shown complete resolution of the iliofemoral thrombosis. Spontaneous DVT in children differ from that in adults in that an underlying etiology can usually be uncovered. These differences are explored.

Endometrioma of the abdominal wall.

We describe a case of a large endometrioma in an abdominal scar and the approach to evaluation and therapy.

Thigh compartment syndrome after acute ischemia.

Thigh compartment syndrome (TCS) is a poorly recognized clinical condition that may follow reperfusion of acutely ischemic thigh muscles. The anterior muscle group appears to be at greatest risk because of its layered arrangement. Intense pain, swelling, and elevated compartment pressures characterize the early presentation in the affected muscle group. If untreated myonecrosis, myoglobinuria, and renal failure may result. TCS was observed in a patient who was treated for a gunshot wound to the left thigh. The superficial femoral and profunda femoris veins as well as the profunda femoris artery were disrupted. The superficial femoral vein and profunda femoris artery injuries were repaired but the mangled branches of the profunda femoris vein were ligated. Postoperatively he developed intense thigh pain, swelling, and elevated compartment pressures. Lateral thigh fasciotomy, extensive debridement of necrotic muscle, and delayed wound closure resulted in a full recovery. Physicians should recognize the numerous clinical circumstances that could lead to TCS--particularly those associated with trauma or physical activity. Timely recognition and intervention may be both limb and life saving. Associated irreparable injury to the profunda femoris vein may aggravate this condition.

Debilitating lymphedema of the upper extremity after treatment of breast cancer.

Lymphedema after mastectomy occurs with a frequency as high as 30%. The incidence increases with more radical surgical dissection, as was often seen with radical mastectomies in the late 1800s. This is one aspect of breast surgery that has been greatly neglected. Surgery has often been deemed a success if the malignancy is eradicated. Patients may complain of symptoms as minor as arm heaviness to major ones such as massive chronic swelling, as was the case with our patient. The patient presented here had increasing lymphedema during a 14-year period after modified radical mastectomy and radiation therapy for advanced breast cancer. This condition had progressed to incapacitation of the extremity and a patient who as a result had become an invalid. The massively edematous extremity revealed no signs of recurrent disease or malignant degeneration. She underwent surgical intervention and physical therapy as procedures of choice to restore function.

Recurrent ischemia in a young man with the antiphospholipid syndrome.

Recurrent thromboses, cerebral disease, miscarriages, and antiphospholipid antibodies are characteristic of the antiphospholipid syndrome. A 31-year-old man presented with limb ischemic and isolated right ventricular failure. Antiphospholipid syndrome was suspected and limb salvage was accomplished by anticoagulation and tibial- to-plantar artery bypass surgery. However, recurrent ischemic episodes were successfully treated with thrombolytic therapy and anticoagulants. The surgeon should be aware that patients with antiphospholipid antibodies and lupus anticoagulant antibodies have a high propensity for recurrent arterial thromboses and should use multiple therapeutic approaches to effect successful long-term limb salvage.

Anomalous origins of the right vertebral, subclavian, and common carotid arteries in a patient with a four-vessel aortic arch.

Many anomalies of the aortic arch and great vessels are uncovered as serendipitous findings on imaging studies, in the anatomy laboratory, or at surgery. A 56-year-old man had an arch angiogram as part of an evaluation for cerebrovascular disease. A four-vessel left aortic arch was identified consisting of the right carotid, left carotid, right subclavian, and left subclavian arteries. The right common carotid gave rise to the right vertebral artery in the chest while the normally located left vertebral arose from the left subclavian artery. No aneurysm or aortic diverticulum was identified.

Metachronous thromboses and myocardial infarctions in a 32-year-old woman with antiphospholipid antibodies.

Metachronous thromboses in multiple vascular beds in a patient younger than 40 years is often suggestive of an acquired or congenital thrombophilic disorder. We present the case of a 32-year-old African American woman who presented to the emergency room with a painful right neck mass and a right hemispheric transient ischemic attack. She had 2 prior admissions for recurrent myocardial infarctions, hypertensive crises, congestive heart failure, and a left ventricular thrombus. Her warfarin therapy expired 2 weeks before her current admission. Our expanded evaluation for thrombophilia revealed high antiphospholipid antibody levels. High-dose anticoagulants were administered without further recurrence or complications. The antiphospholipid antibody syndrome should be considered early in the differential diagnosis as an important cause of recurrent, unusual, or unexplained thromboses in young patients. Education and patient compliance are vital to successful long-term medical management.