Blunt Mesenteric Vascular Injuries: Endovascular Management and Midterm Outcomes.

INTRODUCTION: Visceral artery injuries are rare but lethal entities that pose significant management challenges in a patient who presents with blunt trauma. There is a paucity of specific guidelines both in the trauma and vascular literature regarding the management of blunt intra-abdominal vascular injuries. The midterm outcomes of two cases of blunt traumatic visceral artery injuries managed successfully with endovascular interventions are presented. REPORT: An 18 year old male victim of a motor vehicle accident was found to have infrarenal aortic, coeliac artery (CA), and superior mesenteric artery (SMA) injuries. The second patient was a 15 year old male who presented with traumatic occlusion of the CA after an all terrain vehicle collision. Both patients had other associated abdominal and bony injuries. All vascular injuries were addressed endovascularly, which was followed by repair of other associated injuries. In the first case, a self expanding non-covered nitinol stent was used in the injured but tortuous CA; for repair of the SMA, a covered balloon expandable stent was used. In the second patient, a balloon expandable non-covered stent was used to repair the CA occlusion. In both cases, the 12 month post-operative follow up showed that all stents were patent and the patients were asymptomatic. DISCUSSION: Endovascular repair of the mesenteric arteries following traumatic injury can be achieved safely, with good midterm outcomes. More data are needed to define the indications for and long term safety and patency of stents used in traumatic visceral artery injuries.

Considerations for Long-Term Dialysis Access in Patients with Left Ventricular Assist Devices.

BACKGROUND: Renal dysfunction, requiring renal replacement therapy (RRT) is commonly encountered in patients with left ventricular assist devices (LVADs). Continuous flow LVAD (CFLVAD) is the most widely used device. Nonpulsatile blood flow begets special hemodynamic changes. This poses a unique challenge in choosing a long-term dialysis access for patients with CFLVAD where life expectancy is limited. METHODS: A 61-year-old man with an implanted CFLVAD and renal dysfunction receiving intermittent RRT through a nontunneled dialysis catheter had progressed to dialysis-dependent renal failure. He was referred to us for a permanent hemodialysis access. RESULTS: The patient underwent a right brachio-brachial arterio-venous graft (AVG) placement. The graft was successfully cannulated for hemodialysis on postoperative day 15. On regular follow-up at 18 months, the graft was still functional. CONCLUSIONS: Dialysis access for patients on LVAD is an exceptional management problem owing to both altered physiology and guarded overall prognosis. We recommend the use of AVG as a convenient and durable option-facilitating early cannulation and expediting freedom from indwelling catheters that may lead to catastrophic consequences. This should limit the need for secondary interventions, hospitalization, and cost, thus improving quality of life.

"Inflammatory Bowel Disease-Not Just the Bowel's Bane": Peripheral Arterial and Venous Thrombosis in a Patient With Crohn Disease.

INTRODUCTION: Inflammatory bowel disease (IBD) is a chronic multisystem inflammatory condition with associated endothelial dysfunction and dysregulated coagulation. Although deep venous thrombosis (DVT) in IBD has been well described, arterial thrombosis and thromboembolism are less commonly appreciated. METHODS: A 63-year-old male with a known history of Crohn disease presented with acute-onset right arm pain. His past vascular history was significant for left lower extremity DVT with an existing inferior vena cava filter and acute ischemia of the right lower extremity requiring a below-knee amputation a year ago. Imaging revealed acute brachial, ulnar, and radial artery thrombosis. RESULTS: Patient underwent an open right brachial, radial, and ulnar thrombectomy to restore vascular flow. He required multiple exploration and thrombectomy for reocclusion of the vessels in the early postoperative period. He later developed a rapidly deteriorating clinical status, flank ecchymosis and swelling concerning for soft tissue ischemia, and compartment syndrome heralding an eventual hemodynamic collapse. On exploration, he was found to have chronic fibrosis of his left femoral vein and femoral artery occlusion. Clinically, the patient deteriorated rapidly, which resulted in his demise. CONCLUSION: The inflammatory reaction in IBD leads to arterial stiffening and hypercoagulability, which should theoretically increase the risk for vascular disease. Although the link between IBD and DVT is well established, arterial thrombosis and thromboembolism remain widely debated, with some implications for therapeutic intervention. The link between vascular thrombosis and IBD must be examined further, as the treatment and prevention of vascular complications in IBD depends on our understanding of this relationship.