Endovascular Management of Tracheo-Subclavian Fistula.

Tracheoarterial fistula is a rare complication of tracheostomy with an incidence of less than 1%. Survival of this disease entity is low, and it likely results from a major open operation in a high-risk surgical group. In our review of the literature, a tracheoinnominate artery fistula is the most commonly reported arterial fistula. However, we present a rare case of tracheo-left subclavian artery fistula. We have identified 1 previous case of tracheo-left subclavian fistula as a source of massive tracheal bleeding. In our case report, we describe the successful management of this disease by endograft placement. Owing to its rarity, there are no guidelines on the management approach to tracheoarterial fistulas, but given the difficulty of controlling this problem via median sternotomy, the placement of a covered stent may be the best therapy. Initially, case reports showed a role for endograft placement as a temporizing measure, but the risk of infection may be sufficiently low to justify this approach as a definitive therapy. Upon a 6-month follow-up, our patient remains without recurrence of bleeding or infection, and computed tomography angiography of the chest with 3D reconstruction has shown patency of the endovascular stent with resolution of the associated pseudoaneurysm.

The AngioVac Device: Understanding the Failures on the Road to Success.

OBJECTIVE: Current percutaneous thromboembolectomy techniques may obviate surgical intervention in high-risk patients with iliocaval thrombus or thrombus of the right side of the heart, but typically require thrombus fragmentation and thrombolysis with associated bleeding and thromboembolic complications. The AngioVac (Angiodynamics, Latham, NY USA) device uses a percutaneous venovenous bypass circuit to aspirate intact thrombus. A review of the literature was performed with regard to the AngioVac device to determine the factors correlating with successful thrombus extraction. METHODS: A literature search was performed with regard to use of the AngioVac device using the PubMed database. A meta-analysis was not performed given the small size and lack of statistical analysis of the individual reports included. RESULTS: Twenty-three reports describing 57 procedures in 56 patients were analyzed. Indications for thrombectomy included iliocaval thrombus in 53% (30), thrombus of the right side of the heart, in 49% (28), pulmonary embolus in 14% (8), and upper extremity venous/Glenn shunt thrombosis in 7% (4). The complete success rate, defined as removal of all thrombus, was 75% (43), with an 11% (6) partial success rate. In 14% (8) of cases, minimal or no thrombus was retrieved. When analyzed by indication, iliocaval thrombus and thrombus of the right side of the heart demonstrated 87% (26) and 82% (23) complete success rates, respectively. Pulmonary embolus demonstrated a significantly lower success rate at 12.5% [1; (P < .001)]. Complications occurred in 12% (7), including six hematomas and one retroperitoneal bleed. CONCLUSIONS: The AngioVac device offers an excellent alternative to surgical thrombectomy for patients presenting with iliocaval or intracardiac thrombus, with success rates of more than 80%, although it seems that pulmonary emboli are less amenable. Appropriate patient selection can lead to improved outcomes. Larger numbers are needed to make more definite conclusions.

A hybrid approach in the treatment of post-myocardial infarction ventricular septal defect.

Development of ventricular septal defect (VSD) is a rare but serious complication of transmural myocardial infarction (MI). The incidence of post-MI VSDs is reduced significantly with thrombolytic therapy, yet mortality remains high. Surgical repair is difficult and can be complicated by a recurrent VSD in some cases. Percutaneous catheter-based closure techniques can be used to treat these patients. This case report demonstrates the successful application of a hybrid approach utilizing initial surgical and subsequent percutaneous techniques for the recurrence in the treatment of a post-MI VSD.