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Computed Tomography Angiography With Intra-aortic Catheter Placement in Patients With Stage 4 Renal Failure
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Abstracts
Journal of Vascular Surgery September 2016
Ulnar to Radial Artery Bypass to Treat an Ischemic Hand due to Hypothenar Hammer Syndrome After Radial Artery Harvest Maxwell Almenoff, MD,1 Scott W. Kujath, MD,1,2 Robert R. Carter, MD,1,2 Karl R. Stark, MD,1,2 Jonathan E. Wilson, DO1,2. 1University of Missouri- Kansas City, Kansas City, Mo 2Midwest Aortic & Vascular Institute, North Kansas City, Mo Background: Hypothenar hammer syndrome is rare but occurs with repeated blunt trauma to the hypothenar portion of the hand, resulting in damage to the ulnar artery. This may ultimately lead to digital ischemia. Although controversial, treatment of hypothenar hammer syndrome is typically nonsurgical with anticoagulation if adequate collateral circulation is present. Surgery is reserved for acute and severe ischemia. Radial artery occlusion after radial artery access for coronary intervention occurs up to 5% of the time but is rarely symptomatic. Furthermore, the radial artery is commonly harvested for coronary artery bypass grafting. Although it is rare, acute hand ischemia after radial artery harvest has been described. Case Report: A 62-year-old man presented with 1 week of pain and numbness in the fingertips of his left hand. He had a history of coronary artery bypass surgery using the left radial artery as conduit 12 years prior. He worked in the parts department of a car dealership where he experienced daily trauma to his hands. Computed tomography angiography was done, showing absence of the left radial artery from the elbow to the wrist and occlusion of the left ulnar artery in the distal forearm with reconstitution of the palmar arch through a collateral vessel. A surgical bypass was done between the ulnar artery proximally and the distal stump of the radial artery using a reversed cephalic vein graft. The patient had immediate resolution of his symptoms. Discussion: Our case demonstrates a rare and unreported complication from radial artery harvest for coronary artery bypass in conjunction with hypothenar hammer syndrome. Treatment options included anticoagulation and surgical revascularization. Patients with acute symptomatic ischemia require urgent surgical revascularization. There are multiple options for revascularization, but we chose a reversed cephalic vein graft as it was easily accessible and of good quality. With the increased use of transradial access for cardiac catheterization, hand ischemia may become a more common occurrence as collateral flow to the hand may be compromised. Author Disclosures: M. Almenoff: None; S. W. Kujath: None; R. R. Carter: None; K. R. Stark: None; J. E. Wilson: None.
A 38-Year-Old Man With Marfan Syndrome and Bilateral Subclavian Artery Aneurysms Manju Kalra, MD, Zachary Osborne, MD. Vascular Surgery, Mayo Clinic Rochester, Rochester, Minn A 38-year-old man with Marfan syndrome, with a history of aortic dissection and aneurysmal degeneration that had been previously repaired with a valve-sparing ascending aortic replacement and a thoracoabdominal aorta repair from the ascending repair through the common iliac arteries with renal and mesenteric debranching, presented for asymptomatic bilateral subclavian artery aneurysms found on surveillance imaging. He had a 4-cm aneurysm on the right and a 2-cm aneurysm on the left. He had been lost to follow-up for 5 years. Because of his median sternotomy and his severe pectus excavatum, we thought that a staged cervical hybrid repair was best. He underwent a right subclavian artery repair with reimplantation of the right vertebral artery onto the common carotid and a carotid-subclavian bypass, along with a retrograde exclusion of the right subclavian artery origin with a Gore Excluder (W. L. Gore & Associates, Flagstaff, Ariz). One month later, he developed acute chest and shoulder pain associated with a dissection and enlargement (2 cm to 2.3 cm in 6 weeks) of his left subclavian artery aneurysm. He was subsequently taken for repair of the left subclavian artery by left common carotid to axillary artery bypass, reimplantation of the left vertebral artery onto the left common carotid, and Amplatzer plug occlusion of the prior arch branch to the left subclavian. Postoperatively, the patient did develop a minor hospital-acquired pneumonia that resolved with antibiotics and aggressive pulmonary hygiene. Subclavian artery aneurysms are rarely associated
with Marfan syndrome. We review different approaches to subclavian artery aneurysms. Author Disclosures: M. Kalra: None; Z. Osborne: None.
Computed Tomography Angiography With Intra-aortic Catheter Placement in Patients With Stage 4 Renal Failure Shoaib Shafique, MD,1 Kate Dell, RN2. 1Vascular Surgery, CorVasc MDs, Lafayette, Ind 2St Vincent Medical Group, Lafayette, Ind Objective: The objective of this study was to evaluate the safety of intraaortic catheter placement for computed tomography (CT) angiography performed in patients with stage 4 renal failure. Methods: We chose patients with stage 4 renal failure, defined as calculated glomerular filtration rate <30. These patients needed CT angiography for workup of abdominal aortic aneurysm or occlusive disease. Our protocol required 20 to 40 mL of contrast material mixed with 20 mL of saline in a contrast injector and 60 mL of saline in a saline injector. Contrast agent injection rate was 6 mL/s, and saline injection rate was 3 mL/s. Common femoral artery access was obtained with sonographic guidance with a micropuncture needle. An intra-aortic 5F pigtail catheter was positioned at the level of the midthoracic aorta in the interventional radiology suite. The patient was then transported to the CT suite and examination performed. The scan field was positioned 1 cm above the catheter. The scanner was started 5 seconds after the start of injection of the contrast material. After completion of the examination, the patient was taken back to the interventional radiology suite, and the catheter was removed. A closure device was used at the discretion of the physician. Results: In all cases, we were able to obtain the required information with high-quality images. No patient suffered any complications due to catheter placement. No change in glomerular filtration rate was noted at 30-day follow-up. Conclusions: CT angiography using intra-aortic catheter technique is feasible and safe in patients with stage 4 renal failure in whom limitation of contrast agent volume is critical. Author Disclosures: S. Shafique: None; K. Dell: None.
Staged Reconstruction of the Inferior Vena Cava After Gunshot Injury Nathan Droz, MD, John Matsuura, MD. Department of Surgery, Wright State University, Dayton, Ohio Penetrating injuries with transection of the inferior vena cava carry a high mortality. In a hemodynamically unstable patient, ligation of the vena cava often becomes necessary. The aim of this case report is to describe a delayed reconstruction after stabilization of the patient. A 23-year-old man arrived in the trauma bay with severe hypotension after a gunshot injury to the abdomen. During acute resuscitation, the patient arrested, requiring emergency thoracotomy and aortic cross-clamping. On abdominal exploration, the distal inferior vena cava and the origins of both common iliac veins were transected. The inferior vena cava and both iliac veins were ligated, and an emergency transfusion protocol was initiated. A segment of the small bowel was also resected, leaving the bowel in discontinuity; the patient’s abdomen was packed, and he was transferred to the surgical intensive care unit for resuscitation. The next morning, vascular surgery was consulted for early leg congestion and a second look at the vena cava injury. There was too much loss of venous tissue for direct reconstruction. Because of the presence of bowel contamination in the abdomen, we harvested the right femoral vein and created a bifurcated bypass. The bowel was reanastomosed and the midline fascia was closed. The patient required a second laparotomy because of fever and abdominal pain with a finding of a retained laparotomy sponge. His venous reconstruction was verified patent by duplex ultrasound. This case demonstrates the value of working with the trauma team to delay vena cava reconstruction, when the initial hemorrhagic shock and abdominal contamination are under better control. The patient’s femoral vein provided an excellent size match for his venous reconstruction. Author Disclosures: N. Droz: None; J. Matsuura: None.
Abstracts
Journal of Vascular Surgery September 2016
Ulnar to Radial Artery Bypass to Treat an Ischemic Hand due to Hypothenar Hammer Syndrome After Radial Artery Harvest Maxwell Almenoff, MD,1 Scott W. Kujath, MD,1,2 Robert R. Carter, MD,1,2 Karl R. Stark, MD,1,2 Jonathan E. Wilson, DO1,2. 1University of Missouri- Kansas City, Kansas City, Mo 2Midwest Aortic & Vascular Institute, North Kansas City, Mo Background: Hypothenar hammer syndrome is rare but occurs with repeated blunt trauma to the hypothenar portion of the hand, resulting in damage to the ulnar artery. This may ultimately lead to digital ischemia. Although controversial, treatment of hypothenar hammer syndrome is typically nonsurgical with anticoagulation if adequate collateral circulation is present. Surgery is reserved for acute and severe ischemia. Radial artery occlusion after radial artery access for coronary intervention occurs up to 5% of the time but is rarely symptomatic. Furthermore, the radial artery is commonly harvested for coronary artery bypass grafting. Although it is rare, acute hand ischemia after radial artery harvest has been described. Case Report: A 62-year-old man presented with 1 week of pain and numbness in the fingertips of his left hand. He had a history of coronary artery bypass surgery using the left radial artery as conduit 12 years prior. He worked in the parts department of a car dealership where he experienced daily trauma to his hands. Computed tomography angiography was done, showing absence of the left radial artery from the elbow to the wrist and occlusion of the left ulnar artery in the distal forearm with reconstitution of the palmar arch through a collateral vessel. A surgical bypass was done between the ulnar artery proximally and the distal stump of the radial artery using a reversed cephalic vein graft. The patient had immediate resolution of his symptoms. Discussion: Our case demonstrates a rare and unreported complication from radial artery harvest for coronary artery bypass in conjunction with hypothenar hammer syndrome. Treatment options included anticoagulation and surgical revascularization. Patients with acute symptomatic ischemia require urgent surgical revascularization. There are multiple options for revascularization, but we chose a reversed cephalic vein graft as it was easily accessible and of good quality. With the increased use of transradial access for cardiac catheterization, hand ischemia may become a more common occurrence as collateral flow to the hand may be compromised. Author Disclosures: M. Almenoff: None; S. W. Kujath: None; R. R. Carter: None; K. R. Stark: None; J. E. Wilson: None.
A 38-Year-Old Man With Marfan Syndrome and Bilateral Subclavian Artery Aneurysms Manju Kalra, MD, Zachary Osborne, MD. Vascular Surgery, Mayo Clinic Rochester, Rochester, Minn A 38-year-old man with Marfan syndrome, with a history of aortic dissection and aneurysmal degeneration that had been previously repaired with a valve-sparing ascending aortic replacement and a thoracoabdominal aorta repair from the ascending repair through the common iliac arteries with renal and mesenteric debranching, presented for asymptomatic bilateral subclavian artery aneurysms found on surveillance imaging. He had a 4-cm aneurysm on the right and a 2-cm aneurysm on the left. He had been lost to follow-up for 5 years. Because of his median sternotomy and his severe pectus excavatum, we thought that a staged cervical hybrid repair was best. He underwent a right subclavian artery repair with reimplantation of the right vertebral artery onto the common carotid and a carotid-subclavian bypass, along with a retrograde exclusion of the right subclavian artery origin with a Gore Excluder (W. L. Gore & Associates, Flagstaff, Ariz). One month later, he developed acute chest and shoulder pain associated with a dissection and enlargement (2 cm to 2.3 cm in 6 weeks) of his left subclavian artery aneurysm. He was subsequently taken for repair of the left subclavian artery by left common carotid to axillary artery bypass, reimplantation of the left vertebral artery onto the left common carotid, and Amplatzer plug occlusion of the prior arch branch to the left subclavian. Postoperatively, the patient did develop a minor hospital-acquired pneumonia that resolved with antibiotics and aggressive pulmonary hygiene. Subclavian artery aneurysms are rarely associated
with Marfan syndrome. We review different approaches to subclavian artery aneurysms. Author Disclosures: M. Kalra: None; Z. Osborne: None.
Computed Tomography Angiography With Intra-aortic Catheter Placement in Patients With Stage 4 Renal Failure Shoaib Shafique, MD,1 Kate Dell, RN2. 1Vascular Surgery, CorVasc MDs, Lafayette, Ind 2St Vincent Medical Group, Lafayette, Ind Objective: The objective of this study was to evaluate the safety of intraaortic catheter placement for computed tomography (CT) angiography performed in patients with stage 4 renal failure. Methods: We chose patients with stage 4 renal failure, defined as calculated glomerular filtration rate <30. These patients needed CT angiography for workup of abdominal aortic aneurysm or occlusive disease. Our protocol required 20 to 40 mL of contrast material mixed with 20 mL of saline in a contrast injector and 60 mL of saline in a saline injector. Contrast agent injection rate was 6 mL/s, and saline injection rate was 3 mL/s. Common femoral artery access was obtained with sonographic guidance with a micropuncture needle. An intra-aortic 5F pigtail catheter was positioned at the level of the midthoracic aorta in the interventional radiology suite. The patient was then transported to the CT suite and examination performed. The scan field was positioned 1 cm above the catheter. The scanner was started 5 seconds after the start of injection of the contrast material. After completion of the examination, the patient was taken back to the interventional radiology suite, and the catheter was removed. A closure device was used at the discretion of the physician. Results: In all cases, we were able to obtain the required information with high-quality images. No patient suffered any complications due to catheter placement. No change in glomerular filtration rate was noted at 30-day follow-up. Conclusions: CT angiography using intra-aortic catheter technique is feasible and safe in patients with stage 4 renal failure in whom limitation of contrast agent volume is critical. Author Disclosures: S. Shafique: None; K. Dell: None.
Staged Reconstruction of the Inferior Vena Cava After Gunshot Injury Nathan Droz, MD, John Matsuura, MD. Department of Surgery, Wright State University, Dayton, Ohio Penetrating injuries with transection of the inferior vena cava carry a high mortality. In a hemodynamically unstable patient, ligation of the vena cava often becomes necessary. The aim of this case report is to describe a delayed reconstruction after stabilization of the patient. A 23-year-old man arrived in the trauma bay with severe hypotension after a gunshot injury to the abdomen. During acute resuscitation, the patient arrested, requiring emergency thoracotomy and aortic cross-clamping. On abdominal exploration, the distal inferior vena cava and the origins of both common iliac veins were transected. The inferior vena cava and both iliac veins were ligated, and an emergency transfusion protocol was initiated. A segment of the small bowel was also resected, leaving the bowel in discontinuity; the patient’s abdomen was packed, and he was transferred to the surgical intensive care unit for resuscitation. The next morning, vascular surgery was consulted for early leg congestion and a second look at the vena cava injury. There was too much loss of venous tissue for direct reconstruction. Because of the presence of bowel contamination in the abdomen, we harvested the right femoral vein and created a bifurcated bypass. The bowel was reanastomosed and the midline fascia was closed. The patient required a second laparotomy because of fever and abdominal pain with a finding of a retained laparotomy sponge. His venous reconstruction was verified patent by duplex ultrasound. This case demonstrates the value of working with the trauma team to delay vena cava reconstruction, when the initial hemorrhagic shock and abdominal contamination are under better control. The patient’s femoral vein provided an excellent size match for his venous reconstruction. Author Disclosures: N. Droz: None; J. Matsuura: None.