Graham J. Robinson

Managing inadvertent arterial catheterization during central venous access procedures.

AbstractPurpose: Approximately 200,000 central venous catheterizations are carried out annually in the National Health Service in the United Kingdom. Inadvertent arterial puncture occurs in up to 3.7%. Significant morbidity and death has been reported. We report on our experience in the endovascular treatment of this iatrogenic complication. Methods: Retrospective analysis was carried out of 9 cases referred for endovascular treatment of inadvertent arterial puncture during central venous catheterization over a 5 year period. Results: It was not possible to obtain accurate figures on the numbers of central venous catheterizations carried out during the time period. Five patients were referred with carotid or subclavian pseudoaneurysms and hemothorax following inadvertent arterial catheter insertion and subsequent removal. These patients all underwent percutaneous balloon tamponade and/or stent-graft insertion. More recently 4 patients were referred with the catheter still in situ and were successfully treated with a percutaneous closure device. Conclusion: If inadvertent arterial catheterization during central venous access procedures is recognized and catheters removed, sequelae can be treated percutaneously. However, once the complication is recognized it is better to leave the catheter in situ and seal the artery percutaneously with a closure device.

Carotid Stump Syndrome: Pathophysiology and Endovascular Treatment Options

Carotid stump syndrome is one of the recognised causes of recurrent ipsilateral cerebrovascular events after occlusion of the internal carotid artery. It is believed that microemboli arising from the stump of the occluded internal carotid artery or the ipsilateral external carotid artery can pass into the middle cerebral artery circulation as a result of patent external carotid–internal carotid anastomotic channels. Different pathophysiologic causes of this syndrome and endovascular options for treatment are discussed.

An unusual presentation of pedunculated thrombus in the distal arch of the aorta after splenectomy for B-cell lymphoma

A 59-year-old woman who was asymptomatic after a splenectomy for B-cell lymphoma was found to have a pedunculated mass filling 50% of the aortic lumen within the distal aortic arch on a routine follow-up computed tomographic scan of the chest (A/cover image, and B). She was referred to us with a differential diagnosis of tumor originating from the aortic wall. On transesophageal echocardiogram it seemed to be a solid mass rather than a floating thrombus. With suspicion of malignancy, it was decided to remove the mass surgically. Left thoracotomy was performed, and a 4-cm mass originating from the inner aspect of the distal aortic arch just above the remnant of the ductus arteriosus was excised on partial left heart bypass (C). The histology report showed a cylinder of pale hemorrhagic tissue, 4.0 1.0 0.8 cm, consisting of fibrin thrombus with a few atypical lymphoid cells present at one edge. However, this was insufficient for a firm diagnosis of malignancy. After surgery she received anticoagulant medication for 6 months. She remains well, with no evidence of recurrent thrombus after 3 years of follow-up. Nonaneurysmal aortic arch lesions are a frequent and a stillunderestimated source of stroke and peripheral embolization (in 10% of patients, the source of peripheral embolism cannot be identified). A floating thrombus in an apparently normal aortic arch is considered a life-threatening condition. Although rare, this diagnosis must not be overlooked in the search for etiology of recurrent and disseminated peripheral ischemic events, because of the significant morbidity and mortality related to a delayed diagnosis. Coagulopathies, atherosclerosis, trauma, malignancy, pregnancy, and previous aortic surgery are a few common causes of thrombus formation in this rare condition. There are various treatment options available, such as anticoagulation, balloon thrombectomy, stenting, and surgery. All these therapeutic modalities have their limitations; nonsurgical treatment involves high risk of embolism (reported as a 73% incidence of embolic events for highly mobile aortic thrombi as compared with 12% for immobile ones), ischemia, and stroke, whereas surgery has been reported with high mortality and morbidity. Complicated vascular surgical procedures have been performed for definitive treatment. Primary tumors of the aorta are rare, and only a few cases are reported in the literature; as a result of our suspicion of tumor, we aimed to remove the lesion in a controlled manner under bypass, because no standard approach

Long-term Outcomes of Low-dose Catheter-directed Thrombolytic Therapy: A 5-year Single-center Experience

PURPOSE To determine immediate and long-term outcomes following catheter-directed intraarterial thrombolysis of occluded native arteries and infrainguinal vein grafts by using low-dose tissue-type plasminogen activator (tPA) in patients with lower limb ischemia. MATERIALS AND METHODS One hundred eleven intraarterial thrombolysis procedures were performed in 96 patients during the 2-year study period. Patient records were available for retrospective review in 85 thrombolytic procedures performed in 74 (77%) of the 96 patients. Forty-one native vessels (four iliac, 24 superficial/common femoral, and 13 popliteal/below-knee vessels), six iliac stents, and 38 infrainguinal vein grafts were treated by using a low-dose (0.5 mg/h recombinant tPA) catheter-directed thrombolytic regimen. Procedural success was based on angiographic and clinical outcomes, and the need for further reconstructive surgery or amputation was documented. RESULTS Intraarterial thrombolysis was successful in 76%, was partially successful in 11%, and failed in 13%. Adjunctive angioplasty was performed in 33 of 55 patients (60%) with successful lysis, and immediate reconstructive surgery was required in five patients. There was one episode of puncture site bleeding and one gastrointestinal hemorrhage but no procedure-related deaths at 30 days. After a median follow-up of 6.5 years, 30 of the 55 patients (55%) who underwent successful thrombolysis required no further surgical intervention; however, further surgery was required in 45% of patients after a mean interval of 301 days (range, 2-1,344 days), including 10 (18%) amputations (six major and four minor). CONCLUSIONS Low-dose intraarterial thrombolysis is safe and effective, delaying and dramatically reducing the need for surgical intervention in lower limb ischemia due to native vessel or infrainguinal graft occlusion.

Clinical outcomes following endovascular treatment of the malfunctioning autologous dialysis fistula.

Background: There is limited long‐term prospective data on the use of endovascular techniques and the use of thrombolysis in malfunctioning autologous haemodialysis fistulas.

Replacement tunnelled dialysis catheters for haemodialysis access: Same site, new site, or exchange — A multivariate analysis and risk score

AIM To identify variables related to complications following tunnelled dialysis catheter (TDC) replacement and stratifying the risk to reduce morbidity in patients with end-stage renal disease. MATERIALS AND METHODS One hundred and forty TDCs (Split Cath, medCOMP) were replaced in 140 patients over a 5 year period. Multiple variables were retrospectively collected and analysed to stratify the risk and to predict patients who were more likely to suffer from complications. Multivariate regression analysis was used to identify variables predictive of complications. RESULTS There were six immediate complications, 42 early complications, and 37 late complications. Multivariate analysis revealed that variables significantly associated to complications were: female sex (p = 0.003; OR 2.9); previous TDC in the same anatomical position in the past (p = 0.014; OR 4.1); catheter exchange (p = 0.038; OR 3.8); haemoglobin <11 g/dl (p = 0.033; OR 3.6); albumin <30 g/l (p = 0.007; OR 4.4); prothrombin time >15 s (p = 0.002; OR 4.1); and C-reactive protein >50 mg/l (p = 0.007; OR 4.6). A high-risk score, which used the values from the multivariate analysis, predicted 100% of the immediate complications, 95% of the early complications, and 68% of the late complications. CONCLUSION Patients can now be scored prior to TDC replacement. A patient with a high-risk score can be optimized to reduce the chance of complications. Further prospective studies to confirm that rotating the site of TDC reduces complications are warranted as this has implications for current guidelines.

Inferior Vena Cava Filter from Left-Sided Superior Vena Cava

We describe the unusual case of a 71-year-old male with a history of deep vein thrombosis and recurrent multiple pulmonary embolism (PE) despite adequate anticoagulation. Computed tomography (CT) and brachiocephalic venography revealed a left-sided superior vena cava. We describe successful placement of an inferior vena cava filter via a left-sided superior vena cava.

A novel endovascular technique in the management of a large internal iliac artery aneurysm associated with an arteriovenous fistula

PURPOSE To describe a novel endovascular technique in the management of a complex arteriovenous fistula between a large internal iliac artery aneurysm and the adjacent iliac vein in a 76-year old patient with previous aortobifemoral bypass graft with an occluded proximal common iliac artery. CASE REPORT Due to the high risk of open surgery in this case, endovascular treatment with simultaneous venous and arterial access was performed, with implantation of 2 stent grafts in the iliac vein to cover the fistulous communication and embolisation of the native external iliac artery (inflow). CONCLUSION The endovascular technique described enables thrombosis of the large internal iliac aneurysm and treatment of the arteriovenous fistula without exposing the patient to the high morbidity and mortality associated with open surgery.

Three-year follow-up of fenestrated thoracoabdominal stent graft bridging an endovascular thoracic stent graft and a surgical abdominal aortic graft.

This case report describes repair of a type I endoleak at the distal landing zone of a thoracic aortic stent graft by endovascular placement of a thoracoabdominal fenestrated stent graft (Cook, Brisbane, Australia). The fenestrated stent graft was interposed between a previous abdominal aortic aneurysm (AAA) Gelsoft tube graft (Sulzer Vascutek Ltd, Inchinnan, United Kingdom) and two overlapping Zenith thoracic endografts (Cook Inc, Bloomington, Indiana). Placement was made more complex because the distal thoracic endograft had rotated into a horizontal position. At 3-year clinical and computed tomography (CT) follow-up, continued clinical and radiologic success was shown with no further intervention required.

Pulmonary Arteriovenous Malformations

Like all arteriovenous malformations, pulmonary arteriovenous malformations (PAVM) “steal, shunt, or bleed.” PAVMs are important as systemic venous blood can bypass the lungs, leading to hypoxia or paradoxical embolism. PAVMs tend to increase in size with time