Tarun Grover

Catheter fracture and cardiac migration of a totally implantable venous device

Totally implantable venous devices (TIVD) are increasingly being utilized for venous access for chemotherapy of oncological patients. These devices considerably improve the quality of life of patients requiring long-term chemotherapy. However, despite the great usefulness of TIVDs, their insertion and maintenance is not free of complications. Many early as well as late complications associated with these devices have been reported. We report an unusual, silent, but potentially hazardous complication of catheter fracture and cardiac migration in a 16-year-old girl, in whom the port had been unused for 9 months before presentation. Percutaneous retrieval was unsuccessful as the catheter end was embedded in the myocardium. The catheter was removed via a midline sternotomy without any further complications. We have also reviewed the literature about the possible mechanism of this complication and discussed methods to recognize and avoid it.

Pulmonary Embolism: A Frequent Occurrence in Indian Patients with Symptomatic Lower Limb Venous Thrombosis

OBJECTIVE Pulmonary embolism (PE) is the most severe complication of deep venous thrombosis (DVT). There have been very few studies to assess the prevalence of PE in Asian patients. The objective of this study was to define the prevalence of PE in patients presenting with suspected lower limb DVT. METHODS This was a prospective cohort study at Sir Ganga Ram Hospital, a large multispecialty hospital in New Delhi, India. From January 2001 to July 2004, 1,552 consecutive inpatients and outpatients who presented with clinically suspected lower limb DVT were enrolled in the study. Combined ascending radionuclide venography and lung perfusion scan was performed in all patients. Patients with evidence of pulmonary perfusion defects underwent ventilation lung scan. RESULTS Radionuclide venography-detectable DVT was noted in 744 patients, of whom 521 (70%) had suprapopliteal DVT. Of patients with DVT, 294 (39.5%) showed a high-probability lung scan and 135 (18.1%) had an intermediate-probability lung scan. Overall, 47% of patients with a high-probability scan had no clinical manifestations suggestive of PE. CONCLUSION PE occurs frequently in Indian patients with symptomatic DVT. Increasing awareness will provide us with clearer ideas about the prevalence of venous thromboembolism in Asian countries.

Endovascular Treatment for Peripheral Pulmonary Artery Aneurysm

A 42-year-old male presented with recurrent hemoptysis owing to a leaking peripheral pulmonary artery aneurysm. He was treated with selective coil embolization of the right posterior basal segmental artery to achieve hemostasis. This case is reported for its unsuspected presentation and rarity and to highlight the use of catheter coil embolization to achieve endovascular exclusion of the aneurysm from pulmonary circulation.

Double Barrel In Situ Recanalization of Thrombosed Nonretrievable IVC filter

We report a case of endovascular recanalization of complete thrombotic occlusion of the inferior vena cava (IVC) and bilateral iliac veins using the architectural knowledge of the in situ permanent IVC filter in a 23-year-old male. The infrarenal permanent IVC filter was TRAPEASE permanent vena cava filter (Cordis) placed at an outstation hospital for pulmonary embolism. Being permanent variant of filter, percutaneous removal was not possible. The patient had severe venous claudication and an attempt to recanalize the blocked filter was considered, in view of the age no justifiable indication for a long-term filter. After pharmacomechanical catheter-directed thrombolysis, there was residual focal flow-limiting thrombus within the filter. The design of the Trapease Cordis filter was instrumental in our decision to attempt to recanalize the filter in situ using 2 parallel stents with the filter struts as anchoring pillars in a double-barrel alignment. In similar cases of persistent Trapease filter-related thrombotic occlusion of the IVC, this double barrel in situ recanalization shall be a viable alternative to the well-described technique of crushing the filter and recanalizing it with a single stent.

Vascular access in a rare case of ‘isolated-persistent left superior vena cava’:

A 34-year-old male presented to us after a failed attempt at catheterization for hemodialysis (HD). The patient was taken up in our hybrid angiographic operating room for the procedure which was performed with cardiac monitoring. Venogram through the right internal jugular vein (IJV) showed complete occlusion with no reformation of the normal right-sided superior vena cava. Hence, we had to change our modus operandi and we cannulated the left IJV. Digital subtraction angiography (DSA) revealed a superior vena cava (SVC) that was left sided, incomplete and draining into the right atrium (Figure 1). A longer angiogram confirmed the drainage of the ‘isolated-persistent left superior vena cava (PLSVC)’ into the pulmonary arteries; hence, a temporary HD catheter was safely placed into it. The estimated prevalence of PLSVC is 0.3%–0.5% in the general population and up to 10% in patients with congenital heart disease (CHD). When the PLSVC is associated with incomplete or absent right SVC, it is called isolated PLSVC, which occurs only in 10%–20% of total PLSVC patients and in only 0.09%–0.13% of patients who have CHD.1 When placing a HD/central venous access catheter, the clinician should be aware about the course of the PLSVC. PLSVC usually travels vertically downwards, anterior and to the left of the aortic arch and the main pulmonary artery. Further it runs adjacent to the left atrium, then turns medially and pierces the pericardium to run in the posterior atrio-ventricular groove.1 One should be careful while placing venous access catheters into a PLSVC as abnormal venous return is associated with conduction disturbances and arrhythmias.2 PLSVC usually drains into a dilated coronary sinus and its catheterization can cause hypotension, angina, and perforation of the heart causing tamponade and cardiac arrest. Another possibility is drainage of PLSVC into the left atrium that could result in right to left shunting and paradoxical emboli and could cause venous septic emboli with intra-cerebral empyema.3 Zhou Q et al. have demonstrated in their series of three cases that it is safe and feasible to place long-term venous catheters for dialysis or chemotherapy into the PLSVC. But they also re-iterated that the diagnosis and the detailed anatomic delineation should be done with the help of Vascular access in a rare case of ‘isolatedpersistent left superior vena cava’

Minimally invasive management of renal artery pseudoaneurysm following robotic nephron-sparing surgery: Report of two cases and review of literature

Partial nephrectomy (PN) either done open, laparoscopic, or robotic is associated with the complication of renal artery pseudoaneurysm (RAP), which is rare but can have grave prognosis. Minimally invasive intervention using endovascular techniques can safely treat this problem with minimal morbidity. We present here two cases of RAP following robotic PN. The first case was a 78-year male patient who underwent robotic PN 3 months prior for a 55 mm × 53 mm clear cell carcinoma of the left lower renal pole. On his 3-month follow-up computerized tomography (CT), he was incidentally diagnosed with a 48 mm × 40 mm × 36 mm well-defined pseudoaneurysm with supply from the lower polar accessory renal artery. The second case was a 42-year male patient who had undergone a robotic PN for a 3.5 cm renal mass. On day 24 postsurgery, he developed hematuria and evaluation with renal CT angiography showed two pseudoaneurysms of approximately 8–9 mm each; associated with a hematoma extending from the mid pole of the left kidney to the tail of the pancreas. We managed to successfully embolize the RAPs endovascularly in both the patients; case one with glue and case two with coils. Both patients were discharged on the next day with no side effects, complications, or morbidity. RAP post-PN; though rare, is a dreaded complication that one should be aware of and be able to treat it timely. Knowing how to managing these situations with minimally invasive techniques should be a part of the armamentarium of all endovascular specialists.

Ultrasound-guided fistuloplasty: A novel office-based technique for arteriovenous fistula salvage

Introduction: Alongwith the increasing awareness of fistula for dialysis, there has been an increasing utilization of endovascular interventions to create and maintain native Arterovenous fistulas. So far the widely practiced corrective endovascular options are fistulogram and plasty. However with most target segments being superficial veins of the outflow channel with juxta anastomotic lesions, ultrasound guided fistuloplasty is a promising answer to such a clinical scenario. Methods: All patients with diagnosed outflow vein obstruction with dialysis disturbance and no evidence of central vein stenosis were subjected to the procedure. Results: Satisfactory dialatation was achieved in 84% of patients at the end of one month. Only four patients required adjunctive procedure prior to dialysis. The most common procedure related side effect was hematoma- in 08 ( 19%) of patients, however they were non expanding and self resolving- limited to the area around the plasty site. Conclusion: The procedure can be accomplished in office setting avoiding the exposure of dye and radiation. It also decreases the burden on health care in operating theatres and decreases cost and time of hospitalization. However central vein stenosis and cephalic arch stenosis are definitely limitations of the procedure.

Hybrid Operating Theater Could Increase Role of Endovascular Adjuncts in Peripheral and Thoracic Outlet Vascular Trauma

Trauma is one of the leading causes of mortality and morbidity especially in the young or middle age group. The lethal triad of trauma (hypothermia, coagulopathy, and acidosis) is almost always triggered by initial uncontrolled or concealed hemorrhage. Time is of utmost importance in terminating the vicious cycle. Endovascular interventions along with open surgical management in a hybrid suite not only decrease surgical time, avoid exposure to anesthesia, hasten recovery, but most importantly breakdown the catastrophic sequelae of ongoing bleed by rapid hemorrhage control. They allow vascular control at difficult surgical terrains such as subclavian or iliac vessels with much compared ease and rapidity. We present four interesting cases of peripheral and thoracic outlet vascular trauma and its sequelae managed with endovascular adjuncts at different points in the resuscitative and rehabilitation stations. In our first case of a stab injury over the right femoral artery with acute hemorrhage, a covered stent across the transected artery was curative as well as hastened recovery. In the second case in the hybrid suite, a long segment of balloon occlusion of the iliac artery allowed rapid physiology control and easier surgical repair of the transected common femoral vessels. The third case required a covered stent across the leak from a previously repaired subclavian vessel to prevent life-threatening hemothorax. In another interesting case of a badly mutilated posttraumatic shoulder with an axillary pseudo-aneurysm, a covered stent across the axillary vessel facilitated further reconstructive shoulder surgery.