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Femoral arteriovenous fistula with endarteritis after angioplasty
3
4
Roberts LJ, Beardsworth SA, Trew C. Labour following caesarean section: current practice in the United Kingdom. Br J Obstet Gynaecol 1994; 101: 153-55. Sultan AH, Kamm MA, Bartram CI, Hudson CN. Perineal damage at delivery. Contemp Rev Obstet Gynaecol 1994; 6: 18-24.
Femoral arteriovenous fistula with endarteritis after angioplasty
procedural groin evaluation in patients undergoing coronary angiography. An effort to avoid sheath contamination, especially in obese individuals with a large fatty apron, would seem prudent. Reducing dwell time of the sheaths may also diminish the incidence of this complication. Finally, a high index of suspicion for endarteritis should prevail when unexplained fever or signs of disseminated infection
occur.
M A Siddiqui, D B
SiR-Femoral endarteritis or femoral arteriovenous fistula after percutaneous transluminal coronary angioplasty (PTCA) are uncommon with a reported incidence of less than 1% and 0-02%, respectively.1,z We report a patient who developed both of these entities after PTCA in association with disseminated severe embolic complications. A 61-year-old obese diabetic woman was admitted following inferior wall myocardial infarction. Cardiac catheterisation demonstrated severe right coronary artery stenosis for which she subsequently underwent successful PTCA. The femoral sheath was removed that same day without incident and was in place for a total of 60 hours. The patient thereafter had an uneventful course until she developed malaise and severe joint arthralgias on the day after discharge. On day 13 after discharge she was readmitted with septic shock, bilateral endogenous endophthalmitis, and monoarticular arthritis of the right elbow. Examination of the right groin revealed a prominent continuous femoral bruit without haematoma. Duplex scan of the right femoral vessels showed a common femoral arteriovenous fistula with a small mobile venous thrombus which was subsequently confirmed by left transfemoral arteriography. Diagnostic culture of vitreous fluid from the left eye and the right elbow effusion grew group B streptococcus of similar sensitivities. The patient was placed on high-dose intravenous penicillin therapy for 4 weeks and had surgical repair of the arteriovenous fistula. A Greenfield filter was placed because of the mobile venous thrombus. Except for loss of vision in the left eye, she had no further
sequelae. The criteria for femoral endarteritis after PTCA include of the following manifestations: formation of a pseudoaneurysm found to be purulent upon surgical exploration, evidence of septic emboli, or persistently positive blood cultures in the absence of endocarditis.’Only 18 cases of femoral endarteritis have been previously reported. Pseudoaneurysm of the femoral artery was seen in 7 of 18 patients, all of whom underwent surgical repair. Staphylococcus aureus was the most common organism cultured and was present in 17 of 18 patients. 1 patient was identified as having group A haemolytic streptococcus. All reported patients had either repeat percutaneous puncture of the same femoral artery or intervention through the same sheaths used femoral during diagnostic coronary catheterisation. The femoral sheaths were left in place between 0 and 5 days.1,3,4 In the series of 5 patients with femoral arteriovenous fistula after PTCA reported by Lamar et al,2 all individuals manifested new groin bruits. There were two associated pseudoaneurysms of the femoral artery. All patients underwent successful repair of the fistulous tract which was typically located at the bifurcation of superficial and profunda femoral vessels. Our patient is unusual in having concurrent complications of a femoral arteriovenous fistula as well as femoral endarteritis in association with severe septic dissemination. Also distinct is that the probable cause of the endarteritis was group B streptococcus which was grown from two sites. Finally, formation of a more proximal fistulous tract between the common femoral vessels is apparently unique. This case illustrates the importance of pre-procedural and postone or more
726
The Graduate
1 2
3
4
Vyas, *R M Lester
Hospital, Philadelphia, PA 19146, USA
BW, Flaherty JP. Septic endarteritis of the femoral artery following angioplasty. Rev Infect Dis 1991; 13: 620-23. Lamar R, Berg R, Rama K. Femoral arteriovenous fistula as a complication of percutaneous transluminal coronary angioplasty. Am Surg 1990; 56: 702-06. McCready RA, Siderys H, Pittman JN, et al. Septic complications after Frazee
cardiac catheterization and percutaneous transluminal coronary angioplasty. J Vasc Surg 1991; 14: 170-74. Evans BH, Goldstein EJC. Increased risk of infection after repeat percutaneous transluminal coronary angioplasty. Am J Infect Control
1987; 15: 125-26.
Sensitivity of screening sigmoidoscopy for proximal colorectal tumours has been proposed as a screening test alternative to faecal occult blood testing (FOBT). Endoscopy has a higher sensitivity than FOBT, particularly for adenomas, and sigmoidoscopy is simpler, faster, cheaper, and better tolerated than pancolonoscopy. Since only about 65% of colorectal adenomas are located in the rectosigmoid, this would limit the sensitivity of screening sigmoidoscopy, but it has been observed that most colorectal cancers and adenomas proximal to the descending-sigmoid junction are associated with distal neoplasms. Thus, selecting patients with a positive sigmoidoscopy for further colonoscopy would allow for an adequate sensitivity of a screening programme for colorectal neoplasms.’ Assessing the association of proximal adenomas and cancer with distal neoplasms is not easy as most clinical series of pancolonoscopy are affected by selection biases and are not representative of the general population in terms of prevalence and site distribution of colonic neoplasms. We have reviewed 2937 consecutive FOBT-positive subjects in our files undergoing pancolonoscopy (1346) or a combination of incomplete colonoscopy and double-contrast barium enema (1591) during a population-based screening programmebetween 1980 and 1993. We detected colorectal cancer in 162 subjects and 1354 adenomas in 632 subjects. 53 cancers (32-7%) and 416 adenomas (30-7%) were proximal to the descending-sigmoid junction. Cancer or at least 1 adenoma larger than 9 mm would be detected in 467 subjects if examination were limited to the rectosigmoid, whereas single or multiple distal adenoma(s) smaller than 10 mm would be detected in 293 subjects. Site distribution and association of proximal and distal colorectal cancer and adenomas are summarised in the table.
SiR-Sigmoidoscopy
for colorectal
cancer as an
Table: Site distribution of cancer and adenomas association with distal adenomas
according to
4
Roberts LJ, Beardsworth SA, Trew C. Labour following caesarean section: current practice in the United Kingdom. Br J Obstet Gynaecol 1994; 101: 153-55. Sultan AH, Kamm MA, Bartram CI, Hudson CN. Perineal damage at delivery. Contemp Rev Obstet Gynaecol 1994; 6: 18-24.
Femoral arteriovenous fistula with endarteritis after angioplasty
procedural groin evaluation in patients undergoing coronary angiography. An effort to avoid sheath contamination, especially in obese individuals with a large fatty apron, would seem prudent. Reducing dwell time of the sheaths may also diminish the incidence of this complication. Finally, a high index of suspicion for endarteritis should prevail when unexplained fever or signs of disseminated infection
occur.
M A Siddiqui, D B
SiR-Femoral endarteritis or femoral arteriovenous fistula after percutaneous transluminal coronary angioplasty (PTCA) are uncommon with a reported incidence of less than 1% and 0-02%, respectively.1,z We report a patient who developed both of these entities after PTCA in association with disseminated severe embolic complications. A 61-year-old obese diabetic woman was admitted following inferior wall myocardial infarction. Cardiac catheterisation demonstrated severe right coronary artery stenosis for which she subsequently underwent successful PTCA. The femoral sheath was removed that same day without incident and was in place for a total of 60 hours. The patient thereafter had an uneventful course until she developed malaise and severe joint arthralgias on the day after discharge. On day 13 after discharge she was readmitted with septic shock, bilateral endogenous endophthalmitis, and monoarticular arthritis of the right elbow. Examination of the right groin revealed a prominent continuous femoral bruit without haematoma. Duplex scan of the right femoral vessels showed a common femoral arteriovenous fistula with a small mobile venous thrombus which was subsequently confirmed by left transfemoral arteriography. Diagnostic culture of vitreous fluid from the left eye and the right elbow effusion grew group B streptococcus of similar sensitivities. The patient was placed on high-dose intravenous penicillin therapy for 4 weeks and had surgical repair of the arteriovenous fistula. A Greenfield filter was placed because of the mobile venous thrombus. Except for loss of vision in the left eye, she had no further
sequelae. The criteria for femoral endarteritis after PTCA include of the following manifestations: formation of a pseudoaneurysm found to be purulent upon surgical exploration, evidence of septic emboli, or persistently positive blood cultures in the absence of endocarditis.’Only 18 cases of femoral endarteritis have been previously reported. Pseudoaneurysm of the femoral artery was seen in 7 of 18 patients, all of whom underwent surgical repair. Staphylococcus aureus was the most common organism cultured and was present in 17 of 18 patients. 1 patient was identified as having group A haemolytic streptococcus. All reported patients had either repeat percutaneous puncture of the same femoral artery or intervention through the same sheaths used femoral during diagnostic coronary catheterisation. The femoral sheaths were left in place between 0 and 5 days.1,3,4 In the series of 5 patients with femoral arteriovenous fistula after PTCA reported by Lamar et al,2 all individuals manifested new groin bruits. There were two associated pseudoaneurysms of the femoral artery. All patients underwent successful repair of the fistulous tract which was typically located at the bifurcation of superficial and profunda femoral vessels. Our patient is unusual in having concurrent complications of a femoral arteriovenous fistula as well as femoral endarteritis in association with severe septic dissemination. Also distinct is that the probable cause of the endarteritis was group B streptococcus which was grown from two sites. Finally, formation of a more proximal fistulous tract between the common femoral vessels is apparently unique. This case illustrates the importance of pre-procedural and postone or more
726
The Graduate
1 2
3
4
Vyas, *R M Lester
Hospital, Philadelphia, PA 19146, USA
BW, Flaherty JP. Septic endarteritis of the femoral artery following angioplasty. Rev Infect Dis 1991; 13: 620-23. Lamar R, Berg R, Rama K. Femoral arteriovenous fistula as a complication of percutaneous transluminal coronary angioplasty. Am Surg 1990; 56: 702-06. McCready RA, Siderys H, Pittman JN, et al. Septic complications after Frazee
cardiac catheterization and percutaneous transluminal coronary angioplasty. J Vasc Surg 1991; 14: 170-74. Evans BH, Goldstein EJC. Increased risk of infection after repeat percutaneous transluminal coronary angioplasty. Am J Infect Control
1987; 15: 125-26.
Sensitivity of screening sigmoidoscopy for proximal colorectal tumours has been proposed as a screening test alternative to faecal occult blood testing (FOBT). Endoscopy has a higher sensitivity than FOBT, particularly for adenomas, and sigmoidoscopy is simpler, faster, cheaper, and better tolerated than pancolonoscopy. Since only about 65% of colorectal adenomas are located in the rectosigmoid, this would limit the sensitivity of screening sigmoidoscopy, but it has been observed that most colorectal cancers and adenomas proximal to the descending-sigmoid junction are associated with distal neoplasms. Thus, selecting patients with a positive sigmoidoscopy for further colonoscopy would allow for an adequate sensitivity of a screening programme for colorectal neoplasms.’ Assessing the association of proximal adenomas and cancer with distal neoplasms is not easy as most clinical series of pancolonoscopy are affected by selection biases and are not representative of the general population in terms of prevalence and site distribution of colonic neoplasms. We have reviewed 2937 consecutive FOBT-positive subjects in our files undergoing pancolonoscopy (1346) or a combination of incomplete colonoscopy and double-contrast barium enema (1591) during a population-based screening programmebetween 1980 and 1993. We detected colorectal cancer in 162 subjects and 1354 adenomas in 632 subjects. 53 cancers (32-7%) and 416 adenomas (30-7%) were proximal to the descending-sigmoid junction. Cancer or at least 1 adenoma larger than 9 mm would be detected in 467 subjects if examination were limited to the rectosigmoid, whereas single or multiple distal adenoma(s) smaller than 10 mm would be detected in 293 subjects. Site distribution and association of proximal and distal colorectal cancer and adenomas are summarised in the table.
SiR-Sigmoidoscopy
for colorectal
cancer as an
Table: Site distribution of cancer and adenomas association with distal adenomas
according to