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1.
Ann Vasc Surg ; 67: 563.e7-563.e11, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32234396

RESUMO

We present the case of an iatrogenic injury to the left subclavian artery during placement of a port for chemotherapy. The artery was inadvertently accessed at its infraclavicular position, and then was perforated centrally, entering the mediastinum at the origin of the left vertebral artery. Given that the patient's posterior circulation was largely dependent on the left vertebral artery, it could not be sacrificed. To preserve her left vertebral artery and to avoid the need for a sternotomy, which would more substantially delay initiation of chemotherapy, we elected to perform a hybrid repair: an open left carotid to vertebral artery bypass with reversed great saphenous vein followed by repair of the proximal left subclavian injury with a covered stent graft, which was delivered via the left axillary artery. The patient recovered uneventfully. This case demonstrates a hybrid open and endovascular repair for a complex iatrogenic arterial injury. We were able to obtain a desirable outcome by careful assessment of the anatomic particulars of her injury and the technical constraints in proposed methods of repair, all in the context of the patient's overall goals of care.


Assuntos
Implante de Prótese Vascular , Cateterismo Venoso Central/efeitos adversos , Procedimentos Endovasculares , Doença Iatrogênica , Veia Safena/transplante , Artéria Subclávia/cirurgia , Lesões do Sistema Vascular/cirurgia , Idoso , Prótese Vascular , Implante de Prótese Vascular/instrumentação , Cateterismo Venoso Central/instrumentação , Cateteres de Demora , Cateteres Venosos Centrais , Procedimentos Endovasculares/instrumentação , Feminino , Humanos , Stents , Artéria Subclávia/diagnóstico por imagem , Artéria Subclávia/lesões , Resultado do Tratamento , Lesões do Sistema Vascular/diagnóstico por imagem , Lesões do Sistema Vascular/etiologia
2.
Wounds ; 30(7): 191-196, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30059338

RESUMO

INTRODUCTION: Critical limb ischemia (CLI) is a leading cause of lower extremity amputation. When CLI is identified, revascularization should be performed if possible. When options for revascularization do not exist, use of a noninvasive intermittent pneumatic compression device (NPCD) can be considered. OBJECTIVE: Presented here are 2 cases of patients with nonreconstructable CLI at risk for limb loss who were serially assessed with indocyanine green fluorescence angiography (ICGFA) to determine the effects of NPCD use on local tissue perfusion. MATERIALS AND METHODS: Both patients were treated with the NPCD for 1 hour, 3 times per day, for 4 weeks. Serial ICGFA utilizing a ICGFA device was performed at various time points to monitor the effects of NPCD use on tissue perfusion. RESULTS: The treatment of both patients with serial ICGFA provided limited objective evidence of increased local tissue perfusion which expedited wound resolution. CONCLUSIONS: Larger randomized control trials of this modality of perfusion assessment and NPCD use are recommended.


Assuntos
Angiofluoresceinografia , Gangrena/terapia , Claudicação Intermitente/terapia , Dispositivos de Compressão Pneumática Intermitente , Isquemia/terapia , Salvamento de Membro , Extremidade Inferior/patologia , Estado Terminal , Gangrena/diagnóstico , Gangrena/fisiopatologia , Humanos , Claudicação Intermitente/diagnóstico , Claudicação Intermitente/fisiopatologia , Isquemia/fisiopatologia , Salvamento de Membro/métodos , Masculino , Pessoa de Meia-Idade , Fluxo Sanguíneo Regional , Pele/irrigação sanguínea , Resultado do Tratamento , Cicatrização
3.
J Trauma Acute Care Surg ; 83(2): 230-236, 2017 08.
Artigo em Inglês | MEDLINE | ID: mdl-28459798

RESUMO

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a rescue maneuver for unstable patients with noncompressible hemorrhage below the diaphragm. The efficacy of REBOA in the setting a major abdominal venous injury is unknown. Our objective was to examine the use of REBOA in a large animal model of major abdominal venous injury and characterize any impact on the hemodynamics, rate and volume of hemorrhage, and survival. METHODS: Ten swine (35-55 kg) underwent a controlled and validated hemorrhage and ischemia/reperfusion injury protocol to produce shock physiology. Animals were randomly assigned to a control arm (N = 5) or a treatment (REBOA) arm (N = 5). An injury was then created in the common iliac vein. Bleeding was allowed for 60 seconds and the balloon was then inflated in the REBOA arm. Hemodynamics were recorded for 45 minutes or until death. Blood loss was verified post-mortem and bleeding rate calculated. RESULTS: All animals demonstrated shock physiology at the time of randomization. There were no differences between control versus REBOA animals in baseline mean arterial pressure (42 vs. 50), pH (7.29 vs. 7.26), lactate (6.19 vs. 6.26), or INR (1.2 vs. 1.3, all p = NS). REBOA animals demonstrated immediate improvements in mean arterial pressure (50.6 vs. 97.2, p = 0.04). The mean survival time was 4.1 minutes for controls (100% died) versus 40.1 minutes for REBOA (p < 0.01). There was no difference in total blood loss (mean 630 mL for both). The rate of bleeding was significantly lower in the REBOA animals (control 197 mL/min vs. REBOA 14 mL/min, p = 0.02). CONCLUSION: In the setting of an abdominal venous injury, REBOA improved hemodynamics and lengthened survival time. Blood loss was similar between groups but the rate of bleeding was markedly decreased with REBOA. REBOA appears effective for central venous injuries and provides a sustained period of stabilization and window for surgical intervention.


Assuntos
Traumatismos Abdominais/terapia , Aorta Abdominal , Oclusão com Balão/métodos , Modelos Animais de Doenças , Hemoperitônio/terapia , Veia Ilíaca/lesões , Ressuscitação/métodos , Choque Hemorrágico/terapia , Traumatismos Abdominais/mortalidade , Traumatismos Abdominais/fisiopatologia , Animais , Aorta Abdominal/fisiopatologia , Parada Cardíaca/prevenção & controle , Hemodinâmica/fisiologia , Hemoperitônio/mortalidade , Hemoperitônio/fisiopatologia , Choque Hemorrágico/mortalidade , Choque Hemorrágico/fisiopatologia , Análise de Sobrevida , Suínos
4.
J Vasc Surg Venous Lymphat Disord ; 5(1): 42-46, 2017 01.
Artigo em Inglês | MEDLINE | ID: mdl-27987608

RESUMO

OBJECTIVE: Poor retrieval rates for retrievable inferior vena cava filters (R-IVCFs) have been reported throughout the literature, with poor follow-up a common cause. In 2009, we reported a retrieval rate of 18% despite an initial follow-up rate of 85%. Use of a registry has been shown to improve retrieval rates. As a quality improvement project, in May 2012, the vascular surgery fellowship implemented a reiterative registry to track R-IVCFs placed at Walter Reed National Military Medical Center to improve retrieval rates. We report the results in 125 patients after 38 months. METHODS: Patients receiving an R-IVCF were entered into a registry. All patients were reviewed monthly using an electronic health record. When there was no longer an indication for the R-IVCF, the patient was scheduled for an outpatient appointment with a vascular surgeon followed by retrieval. Rates of retrieval, technical success, dwell time, indication, complications, and demographics were collected. RESULTS: There were 125 R-IVCFs placed between May 2012 and June 2015; 52 filters were placed for therapeutic and 73 for prophylactic indications. Our follow-up rate improved to 94%. A total of 79 filters were retrieved (63% absolute retrieval rate). Excluding patients who died before retrieval and patients with a permanent indication, 77% of filters were retrieved. The average dwell time was 101.5 days (7-460 days), and 63% of successful R-IVCF retrievals were within 3 months of placement. Technical success for retrieval was 92%. There were two major complications from retrievals (1.5% of retrievals). CONCLUSIONS: The creation of an R-IVCF registry promoted ongoing follow-up with patients. In our earlier experience, retrieval rates were poor despite a high follow-up rate. The use of a reiterative registry improved our retrieval rate by 45% and increased our follow-up rate to 94%. These results emphasize the importance of repetitive follow-up for R-IVCFs. Despite a follow-up rate >90%, around a third of R-IVCFs were not retrieved.


Assuntos
Remoção de Dispositivo/normas , Melhoria de Qualidade/organização & administração , Filtros de Veia Cava , Adulto , Idoso , Remoção de Dispositivo/métodos , Remoção de Dispositivo/estatística & dados numéricos , Feminino , Humanos , Assistência de Longa Duração/métodos , Masculino , Maryland , Pessoa de Meia-Idade , Falha de Prótese , Sistema de Registros
5.
Ann Vasc Surg ; 25(1): 133.e9-12, 2011 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-20889292

RESUMO

BACKGROUND: The explosion in endovascular interventions for peripheral vascular disease has resulted in procedures being used by a multitude of specialties. Nonvascular surgeons performing these interventions can create scenarios that may make future vascular interventions difficult. In this article, we present a case report illustrating this point. METHODS: A 68-year-old man with severe chronic obstructive pulmonary disease, coronary artery disease with prior myocardial infarction, and multiple abdominal operations presented with an abdominal aortic aneurysm. In our opinion, this patient was at a prohibitive operative risk for open repair. Review of his imaging results revealed a 6.7-cm infrarenal aneurysm with bilateral common iliac artery (CIA) stents (right: 8 mm; left: 6 mm) and 6-mm self-expanding stents extending from the right external iliac artery through the common femoral artery. A Cook Zenith Renu (30 × 108 mm) graft (Cook Medical Inc., Bloomington, IN) was advanced after serial dilation and balloon angioplasty of the stenotic right CIA stent. Left brachial access was used for arteriographic imaging. The left common femoral artery was accessed and the left CIA was coil-embolized to prevent backbleeding. A femoro-femoral artery crossover bypass was then performed after segmental resection of the right common femoral artery stent. RESULTS: The patient tolerated the procedure well and was discharged home on postoperative day 3. Subsequent postoperative computed tomography arteriogram after 1 month showed palpable pulses and no evidence of endoleak with flow in the femoro-femoral graft on clinical exam. CONCLUSIONS: This case demonstrates an endovascular intervention which limited the potential options available for aneurysm repair. Similar problems may become increasingly common as more providers offer endovascular interventions, thus emphasizing the importance of a collaborative approach to the patient with complex aorto-iliac occlusive disease and abdominal aortic aneurysm. It is the duty of the vascular surgeon to offer his vital expertise and leadership in the care of these patients.


Assuntos
Angioplastia com Balão/instrumentação , Aneurisma da Aorta Abdominal/cirurgia , Arteriopatias Oclusivas/terapia , Implante de Prótese Vascular/instrumentação , Procedimentos Endovasculares/instrumentação , Artéria Ilíaca , Stents , Idoso , Angioplastia com Balão/efeitos adversos , Aneurisma da Aorta Abdominal/complicações , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aortografia/métodos , Arteriopatias Oclusivas/complicações , Arteriopatias Oclusivas/diagnóstico por imagem , Constrição Patológica , Embolização Terapêutica , Procedimentos Endovasculares/efeitos adversos , Humanos , Artéria Ilíaca/diagnóstico por imagem , Masculino , Recidiva , Tomografia Computadorizada por Raios X , Resultado do Tratamento
6.
Vasc Endovascular Surg ; 44(2): 150-4, 2010 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-20034938

RESUMO

INTRODUCTION: Retroperitoneal paragangliomas are rare extraadrenal pheochromocytomas that can involve major vascular structures. RESULTS AND DISCUSSION: A case of periaortic catecholamine-secreting paraganglioma was reviewed and literature search performed to summarize the current surgical management of this disease process. CONCLUSION: Resection for cure of retroperitoneal paragangliomas with vascular reconstruction can be performed with acceptable morbidity and mortality with the use of current vascular techniques.


Assuntos
Aorta/cirurgia , Implante de Prótese Vascular , Catecolaminas/metabolismo , Paraganglioma Extrassuprarrenal/cirurgia , Neoplasias Retroperitoneais/cirurgia , 3-Iodobenzilguanidina , Adulto , Aorta/patologia , Biópsia , Catecolaminas/urina , Feminino , Humanos , Invasividade Neoplásica , Paraganglioma Extrassuprarrenal/metabolismo , Paraganglioma Extrassuprarrenal/patologia , Compostos Radiofarmacêuticos , Neoplasias Retroperitoneais/metabolismo , Neoplasias Retroperitoneais/patologia , Tomografia Computadorizada por Raios X , Resultado do Tratamento
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