Angiojet™ mechanical thrombectomy-induced hemolysis triggering blood-leak alarms.

Blood leak alarms are increasingly rare and may be triggered by rupture of the dialyzer membrane, or intravascular hemolysis. We report two patients who developed hemolysis following Angiojet™ thrombolysis and thrombectomy of thrombosed arteriovenous fistulas, triggering blood leak alarms on hemodialysis, the occurrence of which has not been reported before. AngioJet™-induced hemolysis should be considered in the differential diagnosis for blood leak alarms occurring soon after an intervention on an arterio-venous (AV) fistula.

Broad-Ranging Nutritional Deficiencies Predict Amputation in Diabetic Foot Ulcers.

Diabetic foot ulcers present across the spectrum of nonhealing wounds, be it acute or many months duration. There is developing literature highlighting that despite this group having high caloric intake, they often lack the micronutrients essential for wound healing. This study reports a retrospective cohort of patients' micro- and macro-nutritional state and its relationship to amputation. A retrospective cohort was observed over a 2-month period at one of Australia's largest tertiary referral centers for diabetic foot infection and vascular surgery. Patient information, duration of ulcer, various biochemical markers of nutrition and infection, and whether the patient required amputation were collected from scanned medical records. A cohort of 48 patients with a broad-spectrum of biochemical markers was established. Average hemoglobin A1c (HbA1c) was 8.6%. A total of 58.7% had vitamin C deficiency, including 30.4% with severe deficiency, average 22.6 L} 5.8 µmol/L; 61.5% had hypoalbuminemia, average albumin 28.7 L} 2.5 g/L. Average vitamin B12 was 294.6 L} 69.6 pmol/L; 57.9% had low vitamin D, average 46.3 L} 8.3 nmol/L. Basic screening scores for caloric intake failed to suggest this biochemical depletion. There was a 52.1% amputation rate; biochemical depletion was associated with risk of amputation with vitamin C (P < .01), albumin (P = .03), and hemoglobin (P = .01), markedly lower in patients managed with amputation than those managed conservatively. There was no relation between duration of ulceration and nutrient depletion. Patients with diabetic foot ulceration rely on multidisciplinary care to optimize their wound healing. An important but often overlooked aspect of this is nutritional state, with micronutrients being very important for the healing of complex wounds. General nutritional screening often fails to identify patients at risk of micronutrient deficiency. There is a high prevalence of vitamin deficiency in patients with diabetic foot ulcers. This presents an excellent avenue for future research to assess if aggressive nutrient replacement can improve outcomes in this cohort of patients.

Forgotten Elastic Band as an Unusual Cause of Limb Ulceration: Case Report and Review of the Literature.

We discuss a case of circumferential ulceration of the lower leg in a cognitively impaired elderly man with poor tissue integrity. Thorough clinical examination eventually determined the cause as being a circumferentially placed, forgotten elastic band causing ulceration via sustained tension around the limb. Circumferential application of an elastic band to an extremity is an exceedingly rare but serious cause of lower leg ulceration.

Selective placement of autogenous arteriovenous fistulae in an over 80-year-old population.

INTRODUCTION: With improved life expectancy and quality of life, elderly patients constitute a progressively larger fraction of consumers utilising renal replacement therapy (RRT). Although substantial data exist for younger cohorts, minimal evidence exists for outcomes of arteriovenous fistula (AVF) and central catheters (CVC) placed in those patients over 80 years. We examined outcomes of primary AVF placement in this cohort to ascertain durability and benefits of AVF in the over 80-year-old population. METHODS: Retrospective analysis was undertaken of all autogenous AVFs and CVCs placed in patients aged over 80 years at Gold Coast University Hospital between March 2010 and February 2016. Prospectively collected demographic data, co-morbidities and operative factors were analysed. RESULTS: Sixty-five AVF and 12 CVC patients were identified. Mean age at intervention was 83.9 years and 76% of the patients were male. The majority of procedures were autogenous radio-cephalic AVF; median post-operative length of stay was 2 days. Cumulative AVF patient survival at 12 and 24 months was 82% and 72%, respectively. This was significantly better than survival rates of CVC patients, with 12-month survival of 45%. Primary patency at 6, 12 and 24 months was 58%, 39% and 31%. There were 113 follow-up procedures in 41 patients required to maintain patency. CONCLUSIONS: Although patency rates are inferior and re-intervention rates higher than in younger patients, AVF can be a durable option for RRT in selected elderly patients with improved mortality rates compared with CVC. Age alone should not preclude primary AVF placement.

Short-term outcomes of excisional atherectomy in lower limb arterial disease.

BACKGROUND: Endovascular interventions are increasingly utilized in managing occlusive peripheral vascular disease. Angioplasty and stenting remain the mainstay of endovascular management; however, newer treatment modalities such as excisional atherectomy provide the clinician with additional treatment options. While demonstrating promising results in available trials, a paucity of data exist regarding peripheral atherectomy. The purpose of this retrospective clinical study was to assess the efficacy and safety of excisional atherectomy with the TurboHawk atherectomy device (Covidien/ev3, Plymouth, MN, USA) in the treatment of lower limb peripheral vascular disease and to evaluate the learning curve involved in the institution of a new treatment modality. METHODS: A retrospective analysis was performed on all patients undergoing atherectomy for symptomatic lower limb peripheral vascular disease by a single clinician between November 2011 and June 2013. Forty-seven vessels on 28 legs in 24 patients were treated during the period. RESULTS: Atherectomy was possible in 98% of cases. The 6- and 12-month primary patency was 72.6 and 58.9%, respectively. The primary-assisted patency was 93.2% at 6 months and 74.6% at 12 months. There were significantly greater patency rates in the TransAtlantic Inter-Society Consensus A + B lesions and a non-significant trend towards improved patency rates in claudicants versus critical limb ischaemia. There were four instances of embolization and four cases of dissection. CONCLUSION: Excisional atherectomy provides a further option for the minimally invasive management of peripheral vascular disease. It has similar patency rates to established endovascular therapies and should be considered among the treatment options in patients with favourable pathology.

Medial clavicular osteophyte: a novel cause of paget-schroetter syndrome.

Paget-Schroetter syndrome is a form of upper limb deep venous thrombosis usually seen in younger patients in association with repetitive activities of the affected limb. When occurring in more elderly patients or in those where it is difficult to appreciate a causative mechanism, other aetiologies should be considered. We present a case in which degenerative osteoarthritis of the sternoclavicular joint with osteophyte development impinged on the subclavian vein, leading to extensive upper limb thrombosis. The difficulties in identifying and managing this unusual cause of Paget-Schroetter are presented and discussed.

Novel Treatment of an Enlarging Internal Iliac Artery Aneurysm in Association with a Type 2 Endoleak via Percutaneous Embolisation of the Superior Gluteal Artery through a Posterior Approach.

Internal iliac artery (IIA) aneurysms, while rare, carry a significant risk of mortality if they rupture. Endovascular intervention is now the preferred method of treatment for IIAs; however, due to technical considerations, this is not always feasible. We report a case of a patient who developed an enlarging IIA aneurysm in association with a type 2 endoleak supplied by multiple feeding arteries where conventional endovascular treatment was not possible. A novel method of effectively treating the IIA aneurysm with a posterior approach via image-guided puncture of the superior gluteal artery was employed. Five arteries supplying the superior gluteal from the contralateral internal iliac artery were selectively catheterised and coiled before the aneurysmal sac was embolised. The patient made an uneventful recovery, and follow-up imaging demonstrated resolution of the endoleak and decompression of the aneurysmal sac. This case demonstrates that the posterior approach is a safe and viable method of treating internal iliac artery aneurysm when traditional endovascular approaches are technically possible.