Vascular Complications in Coxiella burnetii Infection: A Report of Two Cases.

Introduction: First described in 1937, Q fever remains a relatively new disease, with much to be learned about its presentation and diagnosis. Due to its role in the development of aortic aneurysms and vascular graft infections, its implications in the vascular domain have become increasingly reported. This is a report of two cases of vascular complications associated with Coxiella burnetii infection, and the challenges in managing their unique presentations. Reports: Case 1: A 70 year old man with a prosthetic aortobiiliac graft and past Q fever infection presented with acute sepsis. Abdominal computed tomography (CT) showed soft tissue thickening and stranding around the graft, and locules of gas within the vessel. Pelvic magnetic resonance imaging (MRI) revealed a chain of abscesses within the right gluteal region, of which aspirate grew Prevotella oris and Escherichia coli. Open explanation of the aortic graft and replacement by superficial femoral vein was performed. Tissue culture confirmed a polymicrobial infection, and PCR of the aortic wall and pre-aortic lymph node was positive for Q fever. He was treated for recrudescent Q fever infection with a good outcome and recovery. Case 2: A 73 year old man had an incidental abdominal aortic aneurysm (AAA) identified at the time of Q fever diagnosis. Following an incomplete course of doxycycline and hydroxychloroquine, the aneurysm rapidly progressed, leading to presentation with right flank pain. Fluorodeoxyglucose (FDG) positron emission tomography (PET) showed multiple foci of uptake within the aneurysm wall. Open AAA repair with a polyester graft was performed, with AAA tissue positive for Q fever on PCR. The operation was successful, with the patient continuing clearance therapy at time of writing. Discussion: Q fever infection poses serious implications for patients with vascular grafts and AAAs, and thus, should be considered in the differential diagnosis of mycotic aortic aneurysms and in aortic graft infections.

Iatrogenic injury to the subclavian artery during central venous access.

Subclavian artery injury during central venous line placement is a potentially life-threatening complication. Due to historically high mortality rates with attempted manual pressure for haemostasis, the current favoured method of repair is by open or endovascular means. This case describes the management of a central venous catheter placed through the internal jugular vein into the subclavian artery via a supraclavicular puncture. CT angiography revealed the arterial injury located 1 cm distal to the vertebral artery origin. Under fluoroscopic guidance in an endovascular hybrid theatre, a covered stent was deployed across the affected segment of the subclavian artery which resulted in occlusion of the vertebral artery origin to attain safe proximal seal. This was done during simultaneous removal of the catheter and manual pressure over the internal jugular vein. There were no complications and the patient recovered well post-procedure. This case highlights the importance of appropriate ultrasound techniques for central catheter insertion for precise visualisation to prevent inadvertent injury to distal structures. CT angiography is useful in planning endovascular management. Occlusion of the vertebral artery in this case did not result in any neurological complications.

Port first vs. Tip first: does difference in portacath insertion techniques reduce complication rates.

BACKGROUND: Accurate placement of central venous access devices is important to avoid complications such as infection, thrombosis and migration. This audit aims to determine if there is a difference in complication rates and accuracy of tip position between two different intravenous jugular (IVJ) port device insertion techniques: fixation of port first (PF) versus tip first (TF). METHODS: Patients who underwent port device insertions from 2019 to 2021 at the Cairns Hospital were identified from the Australia Vascular Audit database. The primary outcome of accurate catheter tip placement (based on radiological criteria), secondary outcomes of line infection, thrombosis and other outcomes such as removal rates were gathered and compared between the 2 groups of port first (PF) versus tip first (TF) insertion. RESULTS: Two-hundred and twenty-seven patients underwent port device insertions during the period of interest. 98 (43.2%) patients had a PF insertion technique and 129 (56.8%) had a TF insertion technique. In the PF group, 81.6% (P < 0.05) of lines were accurately placed compared to 69.8% (P < 0.05) in the TF group. The line related thrombosis rate was 1% (P < 0.05) in the PF group compared to 6.2% (P < 0.05) in the TF group. Rate of line infections in the PF group was 5.1% (P = 0.92) compared to 6.2% (P = 0.92) in the TF group. CONCLUSION: The port first technique for IVJ port device placement was associated with higher accuracy and lower thrombosis rates and this was statistically significant. Further studies should involve larger multicentre populations to compare results between practitioners.

Unusual source of fever: the curious case of an infected arterial stent graft presenting as a ruptured popliteal artery aneurysm.

A 71-year-old man presented to the emergency department with a 1-week history of lethargy, general malaise and intermittent high fever. He had presented 18 months ago, and again 12 months earlier with similar symptoms. On this third presentation, the fever was accompanied by right thigh swelling and pain. The patient was referred to the vascular surgeons with concern regarding an infected vascular stent graft from previous treatment of popliteal artery aneurysms (PAA) 8 years earlier. CT angiogram demonstrated a collapsed right PAA sac with a large collection, consistent with ruptured PAA, and a single gas bubble around the indwelling stent graft. The patient recovered well after a course of antibiotics and surgical explantation of the graft. Infection is a potential complication of any implanted arterial advice, and needs to be considered even years after initial intervention and with no localising symptoms.

Recurrent unilateral cellulitis: is it May-Thurner syndrome (MTS)?

May-Thurner syndrome (MTS) is a differential diagnosis to be considered in a patient with recurrent unilateral cellulitis. A 73-year-old woman initially presented with recurrent unilateral cellulitis of her left lower limb. A CT scan demonstrated a stenosed left common iliac vein (CIV) narrowed at its origin by the proximal right common iliac artery consistent with MTS. The chronicity of the condition at the time of diagnosis made attempts to recanalise the CIV unsuccessful. A diagnosis of MTS should be considered in a patient with chronic unilateral limb oedema/cellulitis as it represents a potentially treatable condition if detected early.

Major lower limb amputations in Far North Queensland.

BACKGROUND: Major lower limb amputation is a devastating operation most commonly performed for complications of peripheral artery disease or diabetes mellitus. Data suggest that there is a widespread variation in major amputation rates within and between countries. This study aimed to identify key characteristics of patients undergoing this procedure in our region, and to compare our population to the rest of Australia. Secondary analysis was performed to assess differences seen in the Indigenous population. METHODS: Cases were identified from a prospectively maintained database and medical records were retrospectively reviewed to record relevant clinical information. A literature review was then undertaken to compare our data to other series. RESULTS: A total of 51 major lower limb amputations were performed between January 2015 and January 2017, and the mean age of patients was 59.5 years. Over 70% of patients were diabetic, and one-third required dialysis. Twenty-three patients were identified as Indigenous, and they were significantly younger (54.6 ± 11.4 versus 63.5 ± 15.9 years, P = 0.02) and more likely to be diabetic (91.3% versus 65.2%, P ≤ 0.01) compared to non-Indigenous patients. The most common indication was arterial ulcer or gangrene (52.9%), but Indigenous patients were more likely to have amputation due to sepsis (47.8% versus 7.1%, P < 0.01). CONCLUSION: Patients undergoing major amputation in Far North Queensland are more likely to be younger and diabetic than Queensland or Australian counterparts. Diabetes and renal disease were especially prevalent in our cohort, with higher rates found in Indigenous patients.

Once versus twice daily low molecular weight heparin for the initial treatment of venous thromboembolism.

BACKGROUND: In the initial treatment of venous thromboembolism (VTE) low molecular weight heparin (LMWH) is administered once or twice daily. A once daily treatment regimen is more convenient for the patient and may optimise home treatment. However, it is not clear whether a once daily treatment regimen is as safe and effective as a twice daily treatment regimen. This is the second update of a review first published in 2003. OBJECTIVES: To compare the efficacy and safety of once daily versus twice daily administration of LMWH. SEARCH METHODS: For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched May 2013) and CENTRAL (2013, Issue 4). SELECTION CRITERIA: Randomised clinical trials in which LMWH given once daily is compared with LMWH given twice daily for the initial treatment of VTE. DATA COLLECTION AND ANALYSIS: Two review authors assessed trials for inclusion and extracted data independently. MAIN RESULTS: Five studies were included with a total of 1508 participants. The pooled data showed no statistically significant difference in recurrent VTE between the two treatment regimens (OR 0.82, 0.49 to 1.39; P = 0.47). A comparison of major haemorrhagic events (OR 0.77, 0.40 to 1.45; P = 0.41), improvement of thrombus size (OR 1.41, 0.66 to 3.01; P = 0.38) and mortality (OR 1.14, 0.62 to 2.08; P = 0.68) also showed no statistically significant differences between the two treatment regimens. None of the five included studies reported data on post-thrombotic syndrome. AUTHORS' CONCLUSIONS: Once daily treatment with LMWH is as effective and safe as twice daily treatment with LMWH.

Varicose veins.

Varicose veins are common and often asymptomatic. A variety of treatment methods are available for those who develop symptoms or complications. The traditional open surgical treatment still forms the mainstay of treatment. Endovenous treatment methods offer a new alternative but have their own limitations. Foam sclerotherapy holds much promise as it can be done in an outpatient setting under local anesthesia, but it needs to be tested over a longer time period.