Kathleen M. Lamb

Preparation and Technical Considerations for Percutaneous Cannulation for Veno-Arterial Extracorporeal Membrane Oxygenation†

The most frequent limb complications from peripheral veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO) are limb ischemia and localized bleeding. To minimize these risks, perfusion of the distal limb with peripheral percutaneous cannulation was done.

Median Arcuate Ligament Syndrome—Review of This Rare Disease

IMPORTANCE Median arcuate ligament (MAL) syndrome is a rare disease resulting from compression of the celiac axis by fibrous attachments of the diaphragmatic crura, the median arcuate ligament. Diagnostic workup and therapeutic intervention can be challenging. OBJECTIVE To review the literature to define an algorithm for accurate diagnosis and successful treatment for patients with MAL syndrome. EVIDENCE REVIEW A search of PubMed (1995-September 28, 2015) was conducted, using the key terms median arcuate ligament syndrome and celiac artery compression syndrome. FINDINGS Typically a diagnosis of exclusion, MAL syndrome involves a vague constellation of symptoms including epigastric pain, postprandial pain, nausea, vomiting, and weight loss. Extrinsic compression of the vasculature and surrounding neural ganglion has been implicated as the cause of these symptoms. Multiple imaging techniques can be used to demonstrate celiac artery compression by the MAL including mesenteric duplex ultrasonography, computed tomography angiography, magnetic resonance angiography, gastric tonometry, and mesenteric arteriography. Surgical intervention involves open, laparoscopic, or robotic ligament release; celiac ganglionectomy; and celiac artery revascularization. There remains a limited role for angioplasty because this intervention does not address the underlying extrinsic compression resulting in symptoms, although angioplasty with stenting may be used in recalcitrant cases. CONCLUSIONS AND RELEVANCE Median arcuate ligament syndrome is rare, and as a diagnosis of exclusion, diagnosis and treatment paradigms can be unclear. Based on previously published studies, symptom relief can be achieved with a variety of interventions including celiac ganglionectomy as well as open, laparoscopic, or robotic intervention.

Successful management of bleeding complications in patients supported with extracorporeal membrane oxygenation with primary respiratory failure.

Background: Extracorporeal membrane oxygenation (ECMO) is a lifesaving procedure in patients with severe respiratory insufficiency failing conventional support. Bleeding complications are common due to the necessity for anticoagulation and circuit-related factors. Methods: A retrospective review was conducted in patients requiring ECMO for respiratory failure from 7/2010 to 6/2011 to identify episodes of major bleeding, bleeding management and outcomes. Results: Twenty-one patients were supported with ECMO during the study although five experienced massive bleeding related to chest tube insertion, jejunal arterio-venous malformations, distal perfusion cannula dislodgement and ventricular rupture. Patients required aggressive resuscitation or endoscopic or operative intervention, totaling 28 procedures. There were no instances of dehiscence, infection or sepsis related to interventions. Anticoagulation was stopped six hours before and restarted 24 hours after major interventions, with no thrombotic or neurologic complications. All patients weaned off ECMO were discharged. Conclusions: ECMO bleeding complications can be managed successfully via surgical and endoscopic approaches in this high-risk population.

Development of unilateral cervical and supraclavicular lymphadenopathy after human papilloma virus vaccination.

A 26‐year‐old woman developed significant unilateral anterior cervical and supraclavicular lymphadenopathy 3 days after receiving her first dose (of a total of three doses) of human papilloma virus (HPV) vaccine. She had no history of lymphadenopathy after other previous immunizations, and had received no vaccines other than HPV at that time. The left‐sided lymphadenopathy developed after she was vaccinated in the left deltoid muscle. The spatial and temporal relationships between the appearance of the lymphadenopathy and receipt of the vaccine in the absence of other causal agents strongly suggest that the HPV vaccine was the causal agent. Use of the Naranjo adverse drug reaction probability scale indicated that the HPV vaccine was a probable (score of 6) cause of the patients adverse reaction. The patient received her second dose of the HPV vaccine 2 months later without further lymphadenopathy. To prevent unnecessary lymph node biopsies and patient concern, clinicians should be aware that lymphadenopathy may occur after HPV vaccination.

Arterial protocol including prophylactic distal perfusion catheter decreases limb ischemia complications in patients undergoing extracorporeal membrane oxygenation

Objective: Venoarterial extracorporeal membrane oxygenation (ECMO) is a salvage therapy in patients with severe cardiopulmonary failure. Owing to the large size of the cannulas inserted via the femoral vessels (≤24‐F) required for adequate oxygenation, this procedure could result in significant limb ischemic complications (10%‐70%). This study evaluates the results of a distal limb perfusion arterial protocol designed to reduce associated complications. Methods: We conducted a retrospective institutional review board‐approved review of consecutive patients requiring ECMO via femoral cannulation (July 2010‐January 2015). To prevent arterial ischemia, a distal perfusion catheter (DPC) was placed antegrade into the superficial femoral artery and connected to the ECMO circuit. Limb perfusion was monitored via near‐infrared spectroscopy (NIRS) placed on both calves. Decannulation involved open repair, patch angioplasty, and femoral thrombectomy as needed. Results: A total of 91 patients were placed on ECMO via femoral arterial cannula (16‐F to 24‐F) for a mean duration of 9 days (range, 1–40 days). A percutaneous DPC was inserted prophylactically at the time of cannulation in 55 of 91 patients, without subsequent ischemia. Of the remaining 36 patients without initial DPC placement, 12 (33% without DPC) developed ipsilateral limb ischemia related to arterial insufficiency, as detected by NIRS and clinical findings. In these patients, the placement of a DPC (n = 7) with or without a fasciotomy, or with a fasciotomy alone (n = 4), resulted in limb salvage; only one patient required subsequent amputation. After decannulation (n = 7), no patients had further evidence of limb ischemia. Risk factors for the development of limb ischemia identified by categorical analysis included lack of DPC at time of cannulation and ECMO cannula size of less than 20‐Fr. There was a trend toward younger patient age. Overall ECMO survival rate was 42%, whereas survival in patients with limb ischemia was only 25%. Conclusions: Limb ischemia complications from ECMO may be decreased by prophylactic placement of an antegrade DPC. Without DPC, continuous monitoring using NIRS may identify limb ischemia, which can be treated subsequently with DPC and or fasciotomy.

Hybrid endovascular treatment of an aberrant right subclavian artery with Kommerell aneurysm

Aberrant right subclavian artery is a rare anatomical finding of abnormal embryologic development of the dorsal aorta and right subclavian artery. An associated aortic outpouching, or Kommerell diverticulum, may develop at the origin of the aberrant right subclavian artery. Given historically high rates of aneurysm rupture and mortality, early repair is indicated. Successful aneurysm exclusion can be accomplished with thoracic endovascular stent grafting following open carotid-subclavian bypass, maintaining upper extremities perfusion. Such hybrid techniques offer a decrease in mortality and complication rates. Herein, we describe a successful repair of a symptomatic (dysphagia, weight loss) aberrant right subclavian artery with Kommerell diverticulum using this hybrid open-endovascular approach.

Diagnosing Cancer in the Symptomatic Patient

Finding cancer at its earliest, most treatable stage gives patients the greatest chance of survival. For a number of cancers, screening tests allow for early detection and treatment, and thereby, reduce cancer-related mortality. However, many cancers are discovered by symptomatic presentation rather than screening. This article addresses several symptoms commonly reported in the primary care setting, including rectal bleeding, a breast lump, cough, lymphadenopathy, and weight loss, and offers an evidence-based approach to the consideration and possibly the diagnosis of cancer.

Full-term pregnancy and vaginal delivery after treatment for non-Hodgkin's lymphoma of the cervix and lower uterine segment: a case report.

BACKGROUND Primary gynaecologic non-Hodgkins lymphomas are rare. We present a case of primary large B-cell lymphoma localized to the lower uterine segment and endocervical stroma that was successfully treated with chemotherapy and immunotherapy. Treatment was followed by a disease-free interval and successful term vaginal delivery. CASE A 21-year-old nulliparous woman presented with dysfunctional uterine bleeding. Radiologic assessment of a posterior lower uterine segment mass and pathologic evaluation of cervical biopsies demonstrated diffuse large B-cell lymphoma involving the endocervical stroma. The patient was treated with chemotherapy and immunotherapy. She had a normal, uncomplicated full-term pregnancy and spontaneous vaginal delivery six years after treatment. CONCLUSION Aggressive diagnosis and treatment of primary non-Hodgkins lymphomas of the cervix do not preclude the possibility of a successful pregnancy and term vaginal delivery.

Vascular site hemostasis in percutaneous extracorporeal membrane oxygenation therapy.

Bleeding is a well described complication of percutaneous extracorporeal membrane oxygenation support (ECMO). In an effort to prevent ongoing percutaneous-cannula blood loss, we tried multiple methods to achieve hemostasis and obtained the best results with QuikClot ® Combat Gauze TM (Z-Medica Corp, Wallingford, CT). This product is made of kaolin, white alumina silicate clay, which initiates activation of the intrinsic clotting cascade. We reviewed our experience in 21 ECMO patients and found 5 patients who required 17 applications of QuikClot ® Combat Gauze TM to percutaneous catheter insertion sites and demonstrated a significant reduction in both localized bleeding complications and the need for blood transfusion. QuikClot Combat Gauze TM , used for the dual purpose of a dressing and hemostatic agent, is a simple valuable method to control pericatheter bleeding in the ECMO population with demonstrated cost savings and clinical utility.

Venous cystic adventitial disease of the common femoral vein

Venous adventitial cystic disease is a rare condition with few reports previously described. We report the case of a 39-year-old female who presented with left lower extremity edema, acutely exacerbated by exercise. Imaging revealed a hypoechoic mass posterior to her left common femoral vein. Open surgical excision and evacuation was performed with resolution of symptoms within 24 hours. A review of the literature is discussed, along with presentation, diagnosis, treatment, and pathology of this intriguing condition.