Glenn Wei Leong Tan

Is Transurethral Catheterisation the Ideal Method of Bladder Drainage? A Survey of Patient Satisfaction With Indwelling Transurethral Urinary Catheters

OBJECTIVE Bladder catheterisation is a routine part of major abdominal surgery. Transurethral catheterisation is the most common method of bladder drainage but is also notorious for its discomfort and increased risk of urinary tract infection. The present study aimed to establish patient satisfaction with transurethral catheterisation and to assess the incidence of clinically significant urinary tract infections after transurethral catheterisation through survey. METHODS All patients who underwent major open abdominal surgery between October 2006 and December 2008 and required standard transurethral bladder catheterisation, were asked to participate in the study. Fifty patients were recruited. RESULTS Male patients were more dissatisfied than their female counterparts with transurethral catheterisation (satisfaction score: 4.18/10 vs. 2.75/10; p = 0.05). Male patients had more than double the score for pain at the urinary meatus with the catheter in situ (p =0.012) and during urine catheter removal (p = 0.013). Half the patients in the study also had symptoms of urinary tract infection after catheter removal. CONCLUSION Our study emphasised the discomfort of transurethral urinary catheters, especially in male patients, and the high incidence of urinary tract infections in both sexes. Consideration should be given to the utilisation of alternative methods of bladder drainage, such as suprapubic catheterisation, which can be performed with ease during laparotomy.

Aortoenteric Fistula Treated With Endovascular Aortic Stent-Graft and Bilateral Chimney Stent-Grafts to Renal Arteries

We report a patient with secondary aortoenteric fistula (AEF) presenting with a rectal bleeding. The patient had multiple comorbidities, precluding major open vascular surgery. We opted to perform a two-stage procedure, where an endovascular stent-graft was first deployed to exclude the AEF from the systemic circulation. As the AEF was at the proximal anastomosis of the previous Dacron graft and close to the renal artery ostia, chimney stent-grafts were placed in both renal arteries to maintain their patency. The second stage of the procedure involved a laparotomy to repair the defect in the duodenum to prevent further contamination from bowel contents.

An unusual case of leiomyosarcoma of the inferior vena cava in a patient with a duplicated inferior vena cava.

Leiomyosarcoma of primary vascular origin is a rare primary soft tissue tumour, which arises mainly from the inferior vena cava (IVC). Clinical symptoms depend upon the size and location of the tumour and presents usually with abdominal pain, palpable mass and weight loss. Complete surgical resection with clear surgical margin plays a central therapeutic role. The effect of chemotherapy and radiation therapy remains to be evaluated. We report a 64 year old Chinese female who presented with abdominal mass and pain associated with weight loss and was subsequently diagnosed with inferior vena cava leiomyosarcoma. She underwent successful surgical resection but unfortunately developed recurrence of tumour 12 month post-operative. She was also found to have a duplicated inferior vena cave which allowed reconstitution of venous return from the lower limbs after surgical resection of the IVC tumour. We discuss the surgical treatment and results of leiomyosarcoma of the IVC.

Management of Blunt Traumatic Thoracic Aorta Injuries With Endovascular Stent-Grafts in a Tertiary Hospital in an Urban Asian City

BACKGROUND Thoracic aortic injury from blunt trauma is a life-threatening condition with significant mortality and morbidity with open surgical repair. Endovascular means of treatment is emerging as an attractive and less invasive option. We report our experience with endovascular stent-graft repair for blunt traumatic thoracic aorta injury. METHODS Between January 2003 and August 2009, six patients underwent endovascular repair of blunt traumatic thoracic aorta injury. Data from the medical records of these patients were analyzed. RESULTS All patients had deceleration injury resulting in thoracic aorta pseudoaneurysm at the aortic isthmus just distal to the left subclavian artery. Four patients were motorcyclists who had been involved in road-traffic accidents and two had fallen from a height. The mean Injury Severity Score was 33.8 (range, 21-43). All procedures were performed within 48 hours of admission and technical success was 100%. Five patients (83.3%) had the left subclavian artery intentionally covered by the stent-graft to achieve adequate proximal landing zone. None of them had any left upper limb ischemic complications or cerebrovascular events after the procedure. One patient had preservation of the left subclavian artery because intraoperative vertebral angiogram showed a hypoplastic right vertebral artery. No other procedural complications, paraplegia, or deaths were reported. Mean follow-up was 18.8 months (range, 1.5-42 months). CONCLUSIONS Our early experience of endovascular stent-grafting for blunt traumatic thoracic aorta injury suggests that this emerging technique is safe for treatment of such pathology in our inherently Asian population. Left subclavian artery may be sacrificed if adequate proximal landing zone is required for the stent-graft; and when vertebral angiogram was performed which did not show a dominant left vertebral artery.

Delayed Recurrence of Type 1A Endoleak with Aortic Rupture and Hemorrhage After Endovascular Aneurysm Sealing (EVAS).

The Nellix endovascular aneurysm sealing system (Endologix, Santa Rosa, CA) or EVAS is a novel endoprosthesis used in endovascular treatment of aortic aneurysm. The current body of literature surrounding EVAS is limited [1–6], and of particular interest is Type 1A endoleak, due to the unique configuration of the proximal seal zone and limited understanding on its natural history [1, 2]. We hereby describe a case of delayed recurrence of type 1A endoleak associated with aortic wall disruption and retroperitoneal hemorrhage. This report fulfills our institution’s criteria for waiver of informed consent.

Use of StarClose Device under Ultrasound Guidance in Inadvertent Carotid Artery Puncture.

evidence of thrombosis, bleeding, or hematoma was found. When the patient presented at the clinic 8 days later for his first visit after the procedure, his swelling had gone down significantly. In-office ultrasound demonstrated patency of the stents and the left femoral vein and right common femoral vein at the access sites. Access site venous bleeding can lead to longer hospital stays, pain, and immobility (1,2), so mitigating this risk has significant value. A few prior studies suggested that vascular closure devices are effective in closing venous access sites even in anticoagulated patients (3,4). The VASCADE device successfully closed the two venous punctures in this case effectively and quickly. Potential advantages of the VASCADE closure device in the venous system include the lack of a thrombogenic intravascular component, a radiopaque disc allowing accurate positioning, and the ability to close holes made by a 10-F (and potentially larger) sheath. The VASCADE vascular closure device is promising; however, further studies are needed to assess the benefits and risks of the VASCADE device in venous access site closure.

Predictors of radio-cephalic arteriovenous fistulae patency in an Asian population.

Purpose To identify predictors of arteriovenous fistula (AVF) patency in Asian patients with autogenous radio-cephalic arteriovenous fistula (RCAVF). Methods Retrospective review of 436 RCAVFs created between 2009 and 2013. Predictors of patency were identified with univariate and multivariate analysis. Kaplan-Meier survival analysis and log-rank test were used to calculate patency rates. Results Overall secondary patency rate was 72% at 12 months, 69% at 24 months, 58% at 36 months, 57% at 48 months, 56% at 60 months and 54% at 72 months. Univariate analysis showed that factors which predict for patency include male gender (p = 0.003), good diabetic control (p = 0.025), aspirin use (p = 0.031), pre-dialysis status (p = 0.037), radial artery diameter (p = 0.029) and non-calcified radial arteries (p = 0.002). Age (p = 0.866), cephalic vein diameter (p = 0.630) and surgeon grade (p = 0.472) did not predict for primary AVF failure. Multivariate analysis revealed the male gender to be an independent predictor for patency (odds ratio 1.99, p = 0.01). Subset analysis showed a significantly larger average radial artery diameter of 2.3 mm amongst males, as compared to 1.9 mm amongst females (p = 0.001) and no statistical difference in the average cephalic vein diameter. Conclusions Within our Asian study population, 12-month patency rate of RCAVF is 72%, 69% at 24 months, 58% at 36 months, 57% at 48 months, 56% at 60 months and 54% at 72 months. Male gender is an independent predictor for RCAVF patency. In females or patients with calcified radial arteries, a more proximal AVF should be considered.

Review of Patency Rates between One-Stage and Two-Stage Brachial-Basilic Transposition Arteriovenous Fistulae Creation in an Asian Population

Objective: To compare patency rates between one- and two-stage (first-stage arteriovenous anastomosis followed by second-stage superficialization) creation of brachial-basilic transposition arteriovenous fistula (BBT-AVF) in an Asian population. Methods: A retrospective review of BBT-AVFs was conducted between July 2008 and March 2015. Kaplan–Meier survival analysis and log-rank test were used to evaluate patency. Results: In total, 103 BBT-AVFs were created in 86 patients (mean age, 61 years; men, 57%). The overall primary, assisted primary, and secondary patency rates at 12, 24, 36, and 48 months were 70%, 48%, 38%, and 35%; 86%, 70%, 62%, and 59%; and 90%, 77%, 70%, and 63%, respectively. There was no significant difference in demographics and preoperative vessel caliber between the groups. The primary failure rate was 24% in the one-stage group, compared with 21% in the two-stage group (p=0.803). There were no statistically significant differences in primary, assisted primary, and secondary patency rates between the groups. Conclusion: There was no significant difference in primary failure and patency rates between the two groups. Both one-stage and two-stage procedures conferred good outcomes with overall 12-month primary patency, secondary patency, and primary failure rates of 70%, 90%, and 23%, respectively.

A Question Mark on Thoracoabdominal Aneurysm

A 73-year-old man presented with an enlarging 5.5-cm Crawford type I thoracoabdominal aneurysm extending from the left subclavian artery to the celiac artery (Fig 1). He was unfit for surgery. To avoid complex customized thoracic and abdominal fenestrated endografts and long aortic segment coverage (with the attendant risk of spinal cord ischemia), two overlapping Multilayer Flow Modulators (Cardiatis, Isnes, Belgium) were deployed in an overlapping fashion (Figs 1–3), extending above the aortic

The IR Point of View: Action Cameras for IR Action

To the Editor, Point of view (POV) or action cameras are lightweight wearable cameras that are popular among sports enthusiasts, with the ability to capture action from the ‘‘first person’’ perspective. Its wearability and ease of operation make it an attractive low-cost investment for real-time broadcast and recording of surgical procedures. Sporadic POV recordings of surgery (including IR procedures) can be found on the internet, alluding to its potential. Recently, limited literature on the use of POV cameras in spine, plastics, and eye surgery have emerged [1–4]. The purpose of this communication is to illustrate the use of POV cameras in IR, highlighting its potentials and limitations. In our institution, available POV cameras (physicians owned) included GoPro HERO 4 (GoPro, Inc., San Mateo, CA) and ThiEYE i60 (ThiEYE Technologies Co., Ltd., Shenzhen, China). They are head-mounted using a headstrap (Fig. 1), with the camera angle adjusted to show the operators hands when the operator looks down. Videos are captured and transmitted in high resolution of 1080 p at 30 frames per second (Movie 1). The cameras come with default wide-angle lens of 152 (ThiEYE) to 170 (Go Pro) field of view (Figs. 1, 2). The cameras are connected via the inbuilt WiFi to a smart phone or tablet running the respective proprietary apps (available on both iOS and Android OS). Once connected, the mobile device will automatically livestream, displaying the POV of the operator. Recordings are then triggered remotely through the apps when required. The demand for live-recording in IR is traditionally less than in surgical disciplines as pertinent procedural details are primarily stored as fluoroscopic images or cine loops and are easily retrievable. The role of POV cameras in IR is therefore supplementary to conventional storage of fluoroscopic images. POV cameras are particularly useful in capturing ‘‘outside the body’’ action that happen in the hands of the operator, such as operation of device consoles (Fig. 3; e.g., atherectomy and endoanchors), complex stent deployment techniques (e.g., interwoven stents), and vascular access/closure techniques (Fig. 2; e.g., transradial access and percutaneous aortic repair), where the hand actions and steps are not captured by fluoroscopy. The educational possibility of POV cameras is intriguing. Livestreaming of operators POV when combined with real-time fluoroscopy in the control room allows for observers to observe the procedure without being in the angiography suite. This is particularly useful during procedures already crowded with multiple operators and teams (e.g., complex aortic repair) and can reduce unnecessary human traffic by keeping observers out of operating room. POV recordings could also be used for audit, self-reflection and teaching, and resident’s POV recordings could be used for competency assessment and retrospectively viewed even without the assessor being on-site. There adaptations needed for the use of POV cameras in IR. The battery life typically allows for approximately Electronic supplementary material The online version of this article (doi:10.1007/s00270-016-1542-8) contains supplementary material, which is available to authorized users.