Victor Tran

Limitations of and Lessons Learned from Clinical Experience of 1,020 Duplex Arteriography

Objective: Due to the inherent risks, deficiencies and cost associated with contrast arteriography (CA), our group has been utitilizing duplex arteriography (DA) for evaluating the arteries of the lower extremity for patients undergoing lower extremity revascularization. In an effort to further explore the strengths and weaknesses of DA, we reviewed our evolving experience with DA from January 1, 1998, to January 1, 2005. Patients and Methods: The arterial segments starting from mid-abdominal aorta to the pedal arteries were studied in cross-sectional and longitudinal planes using a variety of scanheads of 7–4, 10–5, 12–5, 5–2 and 3–2 MHz extended operative frequency range to obtain high-quality B-mode, color and power Doppler images as well as velocity spectra. In 906 patients, 1,020 duplex arteriograms were obtained. The ages ranged from 30–98 years old with a mean of 73±11 (SD) years. Fifty percent of the patients were diabetics. Indications for the examination included: tissue loss (409), rest pain (221), claudication (310), acute ischemia (74), popliteal aneurysm (45), SFA aneurysm (2), abdominal aortic aneurysms (AAA) (10) and failing bypass (55). Prior procedures had been performed in 262. DA was performed by six technologists (4 of whom are MDs). In all, 207 DA were performed intraoperatively and the remainder, preoperatively. Results: The resultant procedures based upon DA included: bypass to the popliteal artery (262) and bypass to an infrapopliteal artery (325), endovascular procedures (363), thrombectomy (11), embolectomy (9), inflow bypass procedures to the femoral arteries (46), débridment (4), amputation (8) and no intervention (75). The areas not visualized well included: iliac (73), femoral (26), popliteal (17), and infrapopliteal (221). Additional imaging after DA was deemed necessary in 102 cases to obtain enough information to plan lower extremity revascularization. Factors associated with increased need to obtain CA included: DM (p<.001), infrapopliteal calcification (p<.001), older age (p = .01) and limb threatening ischemia (p<.001). Factors not associated with the need to obtain CA included: which technologist performed the exam, whether the technologist has a medical degree and whether the patient underwent prior revascularization. Conclusions: In 90% of patients reviewed, DA is able to obtain the needed information to plan lower extremity revascularization. Severe tibial vessel calcification is the most common cause of an incomplete DA exam and determines when alternative imaging modalities need to be obtained.

Superior Vena Cava Perforation Following the Placement of a Superior Vena Cava Filter in Males Less than 60 Years of Age

Although the utility of the superior vena cava (SVC) filter remains controversial, the safety and efficacy of SVC filters in patients with upper extremity deep venous thrombosis in whom anticoagulation is contraindicated or ineffective have been well described. However, few complications have been reported. Herein we describe a series of three cases of SVC perforation in three young males following the placement of SVC filters. All three patients had deep venous thrombosis on upper extremity duplex ultrasonography and contraindication to anticoagulation (n = 1) or failure of anticoagulation (n = 2). Cardiac tamponade was demonstrated on transthoracic echocardiography in all three cases. The pericardial effusion was evacuated with either median sternotomy or pericardiocentesis in two cases. One of the patients died of cardiac arrest, and an autopsy showed aortic perforation in addition to the SVC perforation. This patient underwent chest compression following the cardiac arrest. One patient was lost to follow-up, and the other patient remained asymptomatic at the 1-year follow-up. This is the first case of SVC perforation that is associated with aortic perforation after the placement of an SVC filter. Owing to this occurrence, one has to be aware of these life-threatening complications when placing an SVC filter, especially in males less than 60 years of age.

Use of the StarClose device for closure of inadvertent subclavian artery punctures.

PURPOSE The placement of central catheters is a common procedure. It is also associated with multiple known complications. One of the potential complications that carry high morbidity and morality is arterial puncture and cannulation. Herein, we describe five case reports of a central line that was inadvertently placed in the subclavian artery and successfully removed using a StarClose device (Abbott Laboratories, Redwood CA). METHODS/RESULTS A retrospective chart review of a prospectively maintained database was performed. We identified five cases of inadvertent subclavian artery cannulation during central venous catheter placement. All catheters were removed successfully either in the operating room under fluoroscopic guidance or at the bedside with closure of the arteriotomy using the StarClose device. No cases required conversion to an open procedure for repair. No postremoval hematomas, bleeding episodes, myocardial infarctions, arrhythmias, or adverse clinical sequelae were identified. DISCUSSION Based on our limited experience, we feel that this method can be performed safely and expeditiously not only in the operating room but also at the bedside.

Hybrid Approach for Treatment of Behind the Knee Popliteal Artery Aneurysms

We describe herein a combined approach to the treatment of popliteal artery aneurysms (PAA) that averts extensive dissections and potential blood loss particularly in cases of behind-the-knee aneurysms. Over the last 4 years, 13 patients (12 males) with mean age of 75 ± 8 years were treated for PAAs at our institution with a combined surgical and endovascular approach. The mean size of popliteal aneurysms was 2.9 cm ± 1.7 cm. One of the 13 cases (8%) was performed for acute ischemia and an additional 5 (38%) for claudication. All operations were performed under general anesthesia in supine position. Vein conduits (eight ipsilateral great saphenous veins, two contralateral great saphenous veins and one arm vein) were utilized for 11 bypasses. Of these, eight were from superficial femoral artery (SFA) to below the knee popliteal artery, two popliteal to popliteal and one SFA to posterior tibial artery. In addition, two expanded polytetrafluoroethylene femoral popliteal bypasses were performed. The distal anastomosis was performed after the popliteal artery was ligated distal to the aneurysm. Next, coil embolization of the aneurysmal sac was performed under fluoroscopic or ultrasound guidance. Coils were embolized through a 5F sheath. Lastly, the popliteal artery was ligated distal to the proximal anastomosis. Completion studies were obtained with duplex in six cases and arteriography in the remaining five cases. Mean follow-up was 11.6 months ± 9.6. One bypass occluded in 2 months after surgery. One patient demonstrated continued growth of his aneurysm despite coil embolization twice and underwent an open ligation of the branches perfusing the aneurysm from within the sac through a posterior approach. This approach may be particularly useful for PAAs located behind the knee where optimal surgical exposure is often difficult and the collateral circulation is abundant. The proposed technique is simple, effective and averts extensive dissections required to minimize blood loss.

Bilateral internal iliac artery aneurysm infected with Campylobacter fetus.

This is a case report of a patient with Campylobacter fetus involving bilateral internal iliac artery aneurysms. The patient was treated successfully by ligation of the bilateral iliac artery aneurysms and antibiotics. According to a review of the English-language medical literature, this was the first such patient to be reported. A 69-year-old African-American male presented with a past medical history of repair of a 6.6 cm abdominal aortic aneurysm. It had been repaired with a Dacron bifurcated graft in July 2005. The bilateral internal iliac artery aneurysms (right 2.3 cm and left 3.4 cm) were coil embolized intraoperatively. The patients past medical history was significant for hypertension and coronary artery disease and was status post–stent placement. He re-presented with fever and chills for 8 days in duration at home in March 2007. His fever was 101 to 102°F. He denied vomiting, diarrhea, and a history of recent travel. The patient was admitted to the hospital for a fever workup. After an extensive workup, a left internal iliac artery aneurysm was found to be the source of sepsis. The patient was taken to the operating room for excision of the left internal iliac artery. No purulence was noted, but tissue overlying the aneurysm was thickened and fibrotic. Multiple cultures were taken. The tissue culture came back as C. fetus. Incidentally, the patients preoperative computed tomographic scan revealed a right internal iliac artery aneurysm that was 4.2 cm on March 28, 2007, and 4.9 cm on April 23, 2007. Postoperatively, the patients right internal iliac artery aneurysm was noted to be rapidly growing. He was promptly taken to the operating room for ligation of the right internal iliac artery aneurysm. The patients postoperative course was unremarkable. He was discharged on ciprofloxacin for 14 days.

Effect of Duplex Arteriography in the Management of Acute Limb-Threatening Ischemia From Thrombosed Popliteal Aneurysms.

The role of routine use of duplex arteriography to diagnose thrombosis of popliteal artery aneurysm as a cause of acute lower extremity ischemia is investigated. In all, 109 patients (group 1) from 1994 to 1997 and 201 patients from 1998 to 2001(group 2) presenting with acute limb-threatening ischemia were studied. None of the group 1 patients underwent preoperative duplex arteriography, and no diagnosis of acute popliteal artery aneurysm thrombosis was made. Ten patients with acute ischemia due to thrombosed popliteal artery aneurysm were identified in group 2 when preoperative duplex arteriography was routinely performed. Urgent revascularization was performed based on the results of duplex arteriography. Six patients had functioning bypasses with a mean follow-up of 15.6 months. There were 3 deaths, 2 within 30 days and 1 after 2(1/2) years with functioning grafts. One patient was lost to follow-up. Routine use of duplex arteriography may provide the diagnosis and may identify the available outflow vessels for popliteal artery aneurysm.

Predictive factors of femoropopliteal patency after suboptimal duplex-guided balloon angioplasty and stenting: is recoil a bad sign?

Currently, the value of stenting during femoropopliteal balloon angioplasty (FPBA) remains unclear. Herein we evaluate the patency rates of successful duplex–guided balloon angioplasty (DAGBA) alone versus suboptimal DAGBA followed by stenting and the prestenting dissection versus recoil as potential indicators of stent success or failure. Over a period of 27 months, we performed 291 duplex–guided FPBAs (194 stenoses; 97 occlusions) on 244 limbs in 220 patients. Disabling claudication was the indication in 67%. Critical limb ischemia was the indication in the remaining 33%. Self-expanding nitinol stents were used when plaque dissection and/or recoil caused diameter reduction ≥ 40%. Serial follow-up duplex scans were obtained. Severe restenosis (> 70%) was measured by B-mode imaging and a peak systolic velocity ratio > 3. Follow-up ranged from 1 to 41 months (mean 10 ± 8.3 months). The overall mean interval for restenosis and occlusion was 6.5 ± 4.2 months and 5.6 ± 6.1 months, respectively. Stents did affect overall patency results compared with not using stents. Reasons for stenting were plaque recoil, dissection, or both in 98 (53%), 44 (24%), and 42 (23%) cases, respectively. Six-month patency was 59%, 94%, and 69%, respectively. The difference between plaque recoil and dissection was significant (p < .04). The use of stents during FPBA may be associated with balloon angioplasty site failure in the femoropopliteal segment. To our knowledge, this is the first report ever to document plaque recoil as a predictor of balloon angioplasty site failure notwithstanding stent placement.