Technical success and safety of peripherally inserted central catheters in the great saphenous and anterior accessory great saphenous veins.

BACKGROUND: Peripherally inserted central catheters (PICC) are occasionally placed in the great saphenous vein (GSV) and anterior accessory great saphenous vein (AAGSV) in patients with inadequate upper extremity veins or contraindications to upper extremity placement. Outcomes on the placement of PICCs in these veins are limited. OBJECTIVES: This study aimed to determine technical success and safety of GSV/AAGSV PICCs. MATERIALS AND METHODS: This is a retrospective study that reviewed all GSV/AAGSV PICC placements between January 2011 and December 2019. A total of 29 PICC placements procedures were identified. The electronic medical record was queried for demographic, procedural, and complication data. Technical success was defined by whether the vein could be accessed and a PICC could be placed. Catheter-associated infections, dislodgement or migration, malfunction, and PICC-associated thrombosis were recorded. RESULTS: Technical success of placement was 100%. Twenty-one (72%) catheters were placed in the GSV in the mid to upper thigh and eight (28%) were placed in the AAGSV. The median PICC dwell time was 13 days with a range of 3-155 days. PICC-associated complications occurred after 11 (37.9%) placements. Line associated infection was the most common complication (17.2%). CONCLUSION: Due to a high complication rate, GSV/AAGSV PICC placement should be considered only when upper extremity or cervical PICC placement is not feasible or contraindicated.

Is Long-Term Anticoagulation Required after Stent Placement for Benign Superior Vena Cava Syndrome?

PURPOSE: To identify whether symptom relief and stent patency vary with use of long-term anticoagulation after stent placement for benign superior vena cava (SVC) syndrome. MATERIALS AND METHODS: Patients with benign SVC syndrome treated with stent placement between January 1999 and July 2017 were retrospectively identified (n = 58). Average age was 49 years (range, 24-80 y); 34 (58%) were women, and 24 (42%) were men. Average follow-up was 2.4 years (range, 0.1-11.1 y, SD 2.6). Of cases, 37 (64%) were due to a long-term line/pacemaker, and 21 (36%) were due to fibrosing mediastinitis. After stent placement, 36 (62%) patients were placed on long-term anticoagulation, and 22 (38%) were not placed on anticoagulation. Percent stenosis was evaluated on follow-up imaging by dividing smallest diameter of the stent by a normal nonstenotic segment of the stent and multiplying by 100. RESULTS: Technical success was achieved in all cases. There was no significant difference in number of patients who reported a return of symptoms characteristic of benign SVC syndrome between the anticoagulated (16 of 36; 44.4%) and nonanticoagulated (11 of 22; 50%) groups (P = .68). There was no significant difference in the mean percent stenosis between the anticoagulated (40.4% ± 34.7% [range, 0-100%]) and nonanticoagulated (32.1% ± 29.2% [range, 1.7%-100%]) groups (P = .36). No significant difference was found in the time (days) between date of procedure and date of return of symptoms (anticoagulated, 735.9 d ± 1,003.1 [range, 23-3,851 d]; nonanticoagulated, 478 d ± 826.6 [range, 28-2,922 d]) (P = .49). There was no difference in primary patency between groups (P = .59). Finally, 1 patient (2.8%) in the anticoagulated group required surgical intervention, whereas none in the nonanticoagulated group required surgical intervention. CONCLUSIONS: No significant difference was observed in clinical and treatment outcomes in patients who did and did not receive anticoagulation after stent placement for benign SVC syndrome. Management of benign SVC syndrome after stent placement may not require anticoagulation if confirmed by additional studies.

Comparison of Covered Versus Uncovered Stents for Benign Superior Vena Cava (SVC) Obstruction.

PURPOSE: To identify whether long-term symptom relief and stent patency vary with the use of covered versus uncovered stents for the treatment of benign SVC obstruction. METHODS AND MATERIALS: We retrospectively identified all patients with benign SVC syndrome treated to stent placement between January 2003 and December 2015 (n = 59). Only cases with both clinical and imaging follow-up were included (n = 47). In 33 (70%) of the patients, the obstruction was due to a central line or pacemaker wires, and in 14 (30%), the cause was fibrosing mediastinitis. Covered stents were placed in 17 (36%) of the patients, and 30 (64%) patients had an uncovered stent. Clinical and treatment outcomes, complications, and the percent stenosis of each stent were evaluated. RESULTS: Technical success was achieved in all cases at first attempt. Average clinical and imaging follow-up in years was 2.7 (range 0.1-11.1) (covered) and 1.7 (range 0.2-10.5) (uncovered), respectively. There was a significant difference (p = 0.044) in the number of patients who reported a return of symptoms between the covered (5/17 or 29.4%) and uncovered (18/30 or 60%) groups. There was also a significant difference (p = < 0.001) in the mean percent stenosis after stent placement between the covered [17.9% (range 0-100) ± 26.2] and uncovered [48.3% (range 6.8-100) ± 33.5] groups. No significant difference (p = 0.227) was found in the time (days) between the date of the procedure and the date of clinical follow-up where a return of symptoms was reported [covered: 426.6 (range 28-1554) ± 633.9 and uncovered 778.1 (range 23-3851) ± 1066.8]. One patient in the uncovered group had non-endovascular surgical intervention (innominate to right atrial bypass), while none in the covered group required surgical intervention. One major complication (SIR grade C) occurred that consisted of a pericardial hemorrhagic effusion after angioplasty that required covered stent placement. There were no procedure-related deaths. CONCLUSION: Both covered and uncovered stents can be used for treating benign SVC syndrome. Covered stents, however, may be a more effective option at providing symptom relief and maintaining stent patency if validated by further studies.

Mediastinal seminoma presenting with superior vena cava syndrome.

We present a rare cause of superior vena cava syndrome (SVC) in a previously healthy male aged 31 years. Malignancy was suspected due to unintentional weight loss and childhood exposure to radioactive fallout from a nuclear facility accident. A very large anterior mediastinal mass was identified and demonstrated to be an extragonadal seminoma. Extragonadal germ cell tumours are rare tumours with a high potential for cardiovascular, pulmonary and vascular sequelae. Studies have documented an increased risk of developing seminoma in patients with radioactive exposure. Chemotherapy was initiated, during which the patient experienced progressive and new symptoms, found to be due to extensive thromboembolic disease, which responded well to anticoagulation. Seventy-two months after completing chemotherapy, without need for surgical management, he remains free of the disease.

Occupational health hazards of working in the interventional laboratory: a multisite case control study of physicians and allied staff.

BACKGROUND: The occupational hazards of working in the interventional laboratory have been inadequately studied for physicians and remain unaddressed for nonphysician personnel. OBJECTIVES: This study sought to determine whether the prevalence of work-related musculoskeletal pain, cancer, and other medical conditions is higher among physicians and allied staff who work in interventional laboratories compared with employees who do not. METHODS: Mayo Clinic employees who work in affiliated hospitals with interventional cardiology or interventional radiology laboratories took an electronic survey. Results were stratified on the basis of self-reported occupational exposure to procedures that involve radiation. RESULTS: There were 1,543 employees (mean age 43 ± 11.3 years, 33% male) who responded to the survey (response rate of 57%), and 1,042 (67.5%) reported being involved with procedures utilizing radiation. These employees reported experiencing work-related pain more often than the control group before (54.7% vs. 44.7%; p < 0.001) and after adjustment for age, sex, body mass index, pre-existing musculoskeletal conditions, years in profession, and job description (odds ratio: 1.67; 95% confidence interval: 1.32 to 2.11; p < 0.001). Musculoskeletal pain varied significantly by job description, with the highest incidence reported by technicians (62%) and nurses (60%) followed by attending physicians (44%) and trainees (19%; p < 0.001). There was no difference in cancer prevalence between groups (9% vs. 9%; p = 0.96). CONCLUSIONS: Musculoskeletal pain is more common among healthcare workers who participate in interventional procedures and is highest in nonphysician employees. The diagnosis of cancer in employees who participate in procedures that utilize radiation was not elevated when compared to controls within the same departments, although any conclusion regarding causality is limited by the cross-sectional nature of the study, as well as the low overall prevalence of malignancy in our study group.

Quadrilateral space syndrome: the Mayo Clinic experience with a new classification system and case series.

Quadrilateral space syndrome (QSS) arises from compression or mechanical injury to the axillary nerve or the posterior circumflex humeral artery (PCHA) as they pass through the quadrilateral space (QS). Quadrilateral space syndrome is an uncommon cause of paresthesia and an underdiagnosed cause of digital ischemia in overhead athletes. Quadrilateral space syndrome can present with neurogenic symptoms (pain and weakness) secondary to axillary nerve compression. In addition, repeated abduction and external rotation of the arm is felt to lead to injury of the PCHA within the QSS. This often results in PCHA thrombosis and aneurysm formation, with distal emboli. Because of relative infrequency, QSS is rarely diagnosed on evaluation of athletes with such symptoms. We report on 9 patients who presented at Mayo Clinic with QSS. Differential diagnosis, a new classification system, and the management of QSS are discussed, with a comprehensive literature review. The following search terms were used on PubMed: axillary nerve, posterior circumflex humeral artery, quadrilateral space, and quadrangular space. Articles were selected if they described patients with symptoms from axillary nerve entrapment or PCHA thrombosis, or if related screening or imaging methods were assessed. References available within the obtained articles were also pursued. There was no date or language restriction for article inclusion; 5 studies in languages besides English were reported in German, French, Spanish, Turkish, and Chinese.

Retrievable inferior vena cava filters can be placed and removed with a high degree of success: Initial experience.

OBJECTIVES: Evaluate the success rate of retrievable inferior vena cava filter (IVC) removal in a tertiary care practice. BACKGROUND: Retrievable IVC filters became readily available in the United States following Food and Drug Administration approval in 2003, and their use has increased dramatically. They represent an attractive option for patients with contraindications to anticoagulation who may only need short-term protection against pulmonary embolism. METHODS: All patients who had undergone placement of a retrievable IVC filter at Mayo Clinic between 2003 and 2005 were retrospectively reviewed to evaluate our initial experience with retrievable inferior vena cava filters at a large tertiary care center. RESULTS: During a three-year-period of time, Mayo Clinic, Rochester, MN placed 892 IVC filters of which 460 were retrievable. Of the 460 retrievable filters placed (249 Günther Tulip®, 207 Recovery®, and 4 OptEase®), retrieval was attempted in 223 (48.5%). Of 223 initial attempts, 196 (87.9%) were initially successful and 27 (12.1%) were unsuccessful. Of the 27 unsuccessful initial retrieval attempts, 23 (85.2%) were because of the presence of significant thrombus within the filter and 4 (14.8%) were because of tilting and strut perforation. Of the 23 filters containing significant thrombus, 9 (39.1%) were later retrieved after a period of anticoagulation and resolution of the thrombus. CONCLUSIONS: Retrievable IVC filters can be removed with a high degree of success. Approximately one in ten retrievable IVC filter removal attempts may fail initially, usually because of significant thrombus within the filter. This does not preclude possible removal at a later date.

Digital obstructive arterial disease can be detected by laser Doppler measurements with high sensitivity and specificity.

OBJECTIVE: This study was conducted to determine the sensitivity and specificity of laser Doppler flowmetry (LDF) measurements for digital obstructive arterial disease (DOAD) using angiography as the reference standard and to compare the accuracy of different classical tests used to assess DOAD. Diagnosis of vascular abnormalities at the digital level is challenging. Angiography is the gold standard for assessment of DOAD but is invasive and expensive to perform. METHODS: We performed a retrospective analysis of consecutive patients referred at Mayo Clinic (Rochester, Minn) for upper extremity arterial assessment during a 27-month period. Finger-brachial index, skin blood flow (in arbitrary units [a.u.]), and skin temperature (in degrees Celsius) were recorded in each digit on the pulp at baseline and after a thermal challenge test (hand placed in a thermal box at 47.0°C for 15 minutes). Angiogram analysis was blinded and performed by a radiologist using a vascularization scale ranging from 0 (no vessel) to 4 (normal). The receiver operating characteristic curve was used to define a specific cutoff point to detect DOAD. Twenty-two patients had LDF measurements and complete angiograms. RESULTS: A total of 185 digits were analyzed because some patients had only analysis of one hand. The best area under the curve (AUC) was 0.98 (range, 0.94-0.99) for postwarming skin blood flow, with a cutoff point of ≤206 a.u. This AUC was statistically different from AUCs of all the other tests (P < .01). Sensitivity and specificity were 93% (95% confidence interval, 85%-97%) and 96% (95% confidence interval, 90%-99%), respectively. CONCLUSIONS: LDF combined with a thermal challenge is highly accurate, safe, and noninvasive means to detect DOAD.

Inflammatory abdominal aortic aneurysm: a case report and review of literature.

We report a case of an abdominal aortic aneurysm (AAA) that underwent inflammatory transformation which we treated medically with corticosteroids. Medical therapy resulted in resolution of presenting symptoms and observed inflammatory changes. We review the clinical features, associated pathology, diagnostic, and therapeutic options in the management of inflammatory AAA.

Prevalence of abdominal wall hernia in participants with abdominal aortic aneurysm versus peripheral arterial disease--a population-based study.

Small studies suggest an association between abdominal aortic aneurysms (AAAs) and hernias, possibly related to connective tissue weakness. We evaluated the association between AAA and abdominal wall hernia (AWH), using peripheral arterial disease (PAD) patients as controls, in Olmsted County, Minnesota. In a retrospective cohort study we queried the electronic medical records for the diagnosis of AAA. The resulting data were then queried for prevalence of AWH. The same set of queries was repeated for PAD. Occurrence of AWH in the 2 groups was compared using the chi-square test. Of the 187 151 patient records queried, 939 had AAA and 3465 had PAD. Abdominal wall hernia occurred in 157 (16.7%) patients with AAA and in 343 (9.9%) patients with PAD. Abdominal wall hernia was 1.7 times more prevalent in those with AAA versus PAD (P < .0001). A history of hernia may prompt screening for AAA in some patients.

Embolic strokes after peripherally inserted central catheter placement.

Peripherally inserted central catheters (PICCs) have become popular for a range of indications in both inpatient and outpatient settings. Though PICCs are generally safe, they can be associated with a variety of complications. We present here a case with embolic strokes due to inadvertent arterial placement of PICC, an uncommon but potentially life-threatening complication. A high clinical suspicion with critical evaluation of radiographs is indispensable for suspecting misplaced PICCs.