Pseudoaneurysm Formation After "Preclose"-Assisted Impella Insertion in a Patient With Cardiogenic Shock.

The use of mechanical support devices such as the Impella CP (Abiomed, Danvers, MA) is a growing form of treatment for patients with cardiogenic shock (CS). Despite the increase in usage, there remains a dearth in literature regarding potential complications. Vascular complications such as pseudoaneurysms (PAs) are rare but important potential complications that can occur with use of the Impella. We present Impella-assisted percutaneous coronary intervention (PCI) in a patient with CS, "Preclosed" with the Perclose ProGlide (Abbott, Plymouth, MN) device complicated by development of a PA. A 62-year-old male patient with a history of diabetes and hypertension presented to our emergency room (ER) with chest pain and electrocardiogram (ECG) findings consistent with an acute anterior wall ST-elevation myocardial infarction (STEMI). This was further complicated by refractory CS. The patient was urgently taken to the cardiac catherization laboratory. After exchange of sequential dilators, a single Perclose device was used prior to the insertion of the Impella sheath. The patient then underwent a successful Impella-assisted PCI of his left anterior descending artery. Upon stabilization of hemodynamics, the patient was taken to the catheterization laboratory for Impella removal. After removal of Impella, imaging detected extravasation of contrast, without development of hematoma, later confirmed to be a PA via computed tomography (CT) scans and ultrasound Doppler imaging. The PA was successfully managed with injection of thrombin. The PA was likely caused by shearing forces of the dilators, the 14-F Impella sheath and foot of the device. We propose deploying the Perclose device earlier in the process of dilating the access site to avoid such complication. This is one of the first case reports that detail the occurrence and management of a PA with Impella insertion.

Salvage of Suboptimal or Occluded Arteriovenous Fistulas Using a 4 French System From the Radial Artery for Initial Balloon Angioplasty Maturations.

Introduction End-stage renal disease (ESRD) is a condition that has seen a large increase in prevalence in recent decades. Paralleling this increase in prevalence is the increasing number of patients requiring vascular access for hemodialysis. Arteriovenous fistulas (AVFs) and arteriovenous grafts (AVGs) are considered the procedures of choice for hemodialysis access. However, due to the suboptimal venous anatomy (<2 mm diameter, sclerotic vascular walls) and chronic medical conditions (diabetes mellitus) seen in many ESRD patients, successful AVF creation and maturation is not always possible using standard procedures. In this study, we performed primary balloon angioplasty (PBA) at the time of AVF creation with subsequent balloon angioplasty maturation (BAM) procedures in a group of patients with a large proportion of diabetes and suboptimal venous anatomy. The purpose of this study was to compare the assisted patency and survival rates in patients with suboptimal veins used to create AVFs to patients with standard vein AVFs and AVGs.  Methods Over a nine-year period, PBA during AVF creation was performed 682 times. Of these, 551 AVFs were matured in optimally sized veins using standard BAM procedures, and 131 AVFs were matured in suboptimal veins utilizing a modified approach. In the subset of patients with suboptimal venous anatomy, we performed the initial BAM procedure via the radial artery utilizing a 4 French system. Additionally, routine clinical surveillance was scheduled throughout the study period for all patients. Suboptimal veins included small (<2 mm diameter), sclerotic, accessory, or recanalized veins. During the study period, 69 AVGs were created and matured using standard graft-gram procedures. A Kaplan-Meier analysis of survival and assisted patency rates comparing the three groups were calculated utilizing data from a retrospective database and medical records. A hazard ratio and a log-rank test were calculated to assess statistical significance. Results The mean time of follow-up for all three groups (n=703) was 43.2 months. Among patients requiring hemodialysis access in the study, the fistula creation rate was 90.8%. Patients with suitable venous anatomy who underwent AVF creation with PBA and standard BAM procedures experienced higher primary assisted patency rates relative to the suboptimal vein AVF and AVG groups (p<0.0001). No difference was seen between the suboptimal vein AVF and AVG groups. Patient survival and the percentage of diabetics were comparable amongst all three groups. Conclusion Using our approach, we were able to achieve a high AVF creation rate amongst a group of patients with a large proportion of suboptimal veins and diabetes. Despite not performing as well as standard vein AVFs in regards to primary assisted patency, the patients with suboptimal vein AVFs experienced similar patency and survival rates as compared to patients receiving AVGs. This new approach enhances the ability to create AVFs in patients who would otherwise not be amenable to fistulas and may contribute to reduced complication risk and improved overall survival.

Overview of the Pathogenesis and Treatment of SARS-CoV-2 for Clinicians: A Comprehensive Literature Review.

In December 2019, numerous cases of "pneumonia of unknown origin" were presenting throughout Wuhan, China. The pathogen was described to be a novel coronavirus and was subsequently classified as SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) due to similarities in its pathogenesis and conserved replicase sequence with SARS-CoV-1 (severe acute respiratory syndrome coronavirus 1). Containment measures were initiated; however, the virus began to spread rapidly to countries around the world, and on March 11, 2020, the World Health Organization (WHO) declared a worldwide pandemic. Since the WHO's declaration, the scientific community has produced an abundance of information about this virus. In this report, we provide a comprehensive review of original articles, clinical trials, and case series in order to produce a concise overview of the pathogenesis and treatment of SARS-CoV-2 (COVID-19 [coronavirus disease 2019]) for clinicians. This review includes data on the roles of the S protein, ACE2 (angiotensin-converting enzyme 2) receptor, and various human secretory proteases, such as transmembrane protease/serine subfamily member 2 and furin, in the pathogenesis of SARS-CoV-2. In addition, a thorough review of treatment options including oxygenation/ventilation strategies, dexamethasone, remdesivir, chloroquine/hydroxychloroquine, immune-based therapies, and anticoagulation are included. Information on this topic is changing rapidly but the authors believe that this review serves as an accurate representation of the current state of knowledge on these topics.

Single Tertiary Care Center Outcomes After Lower Extremity Cadaveric Vein Bypass for Limb Salvage.

OBJECTIVE: Cadaveric saphenous vein (CV) conduits are used in rare instances for limb salvage in patients without autogenous veins although long-term outcome data are scarce. This study was designed to evaluate the outcomes of CV bypass in patients with threatened limbs. METHODS: We retrospectively reviewed the charts from 2010 to 2017 of 25 patients who underwent 30 CV allografts for critical limb ischemia and acute limb ischemia. Patient charts were reviewed for demographics, comorbidities, smoking status, indications for bypass, and outcomes. Primary outcomes included graft patency, major amputation rates, and mortality. Secondary outcomes measured included infection rates, 30-day major adverse cardiac events (MACE) and major adverse limb events (MALE). Statistical analysis was performed using time series and Kaplan-Meier survival curves. RESULTS: A total of 30 limbs received CV lower extremity bypasses (20 males, 10 female), and the average age was 68 ± 4 years. Primary patency rates were 71%, 42%, and 28% at 3, 6, and 12 months, respectively. Assisted primary patency rates were 78%, 56%, and 37% at 3, 6, and 12 months, respectively. Secondary patency rates were 77%, 59%, and 28% at 3, 6, and 12 months, respectively. Minor amputations, defined as amputations below the transmetatarsal level occurred in 5 (20%) patients. Wound infection occurred in 8 (32%) patients which was managed with local wound care and no patients required an extraanatomic bypass for limb salvage. Thirty-day MALE occurred in 7 (23.3%) patients. We had no 30-day mortality or MACE. The average graft length was 64.2 ± 8 cm with an average graft diameter of 3.9 ± 2 mm. Amputation-free survival and overall survival at 12 months were 20 (68%) and 21 (84%), respectively. CONCLUSIONS: Cadaveric saphenous vein allograft may be used as a bypass conduit as a viable surgical option before limb amputation. Despite the poor patency rates, the limb salvage rates of cadaveric vein grafts demonstrate that this alternate conduit may be considered when no autogenous vein is available.