From the Divisions of Thoracic/Vascular Surgery (R.K.-J., M.L.), and Interventional Radiology (R.B.) Peacehealth Southwest Washington Medical Center, Vancouver Wa. Submitted: January 14, 2020, Accepted: February 1, 2020, Published online: March 12, 2020. Address for reprints: Riyad Karmy-Jones, MD, 505 NE 87th Ave, Bldg B, Suite 300, Vancouver Wa 98664; email: [email protected].

Blunt carotid artery injuries are uncommon, usually occur in a delayed fashion, and most commonly after significant blunt-force mechanism. Choke holds, use of pressure points, and other close-combat techniques used in military or mixed martial arts training can have the same kinetic impact as a motor vehicle crash. We present an unusual case of common carotid fibrosis which required surgery and suggest that duplex ultrasound might be an appropriate screening tool in those who regularly participate in such training.

BACKGROUNDCatheter thrombectomy combining thrombus destruction with local thrombolysis has been used in patients with pulmonary embolism (PE) who are unstable or have significant right heart dysfunction, but have contraindications to systemic thrombolytic therapy.OBJECTIVESTo assess the outcomes of patients who underwent pulmonary embolectomy using a commercially available thrombectomy device.METHODSA retrospective chart review of patients who underwent pulmonary embolectomy between March 2007 and August 2009 was performed. Patients were classified as having clinical massive or submassive PE, and moderate or severe right ventricular dysfunction. Data collected included pre- and postprocedure shock index (heart rate divided by systolic blood pressure) and mean pulmonary artery pressure.RESULTSSixteen patients with a mean (± SD) age of 54.4 ± 15.8 years underwent embolectomy. Five had clinical massive PE (two in cardiogenic shock) and three of 11 submassive cases had severe right ventricular dysfunction. All were deemed to have contraindications to systemic lysis. Both shock index (1.02 ± 33 preintervention versus 0.71 ± 0.2 postintervention [P=0.001]) and mean pulmonary artery pressure (34.5 ± 9.9 mmHg preintervention versus 27.1 ± 7.1 postintervention [P=0.01]) improved. In the massive PE group, one patient died and two survivors experienced retroperitoneal bleeding and transient renal failure. At follow-up (17.3 ± 7.8 months), two patients in the massive PE group demonstrated evidence of mild cor pulmonale.CONCLUSIONRheolytic thrombectomy is an effective strategy in managing massive PE, particularly in patients who have well-defined contraindications to systemic lytic therapy. The effectiveness of rheolytic thrombectomy for submassive PE is not as well defined, but warrants a comparison with systemic lytic therapy.

A patient with concomitant rupture of the thoracic aorta and right subclavian artery at its origin was managed with endovascular stents. Due to the patient's hypovolemic shock, kissing stents in the brachiocephalic artery were undersized, requiring repeat intervention with coils and cement. The technical and judgment aspects of this case are reviewed. (Ann Thorac Surg 2011; 91: 281-3) (C) 2011 by The Society of Thoracic Surgeons

Traumatic thoracic aortic injury remains a major cause of death following motor vehicle accidents. Endovascular approaches have begun to supersede open repair, offering the hope of reduced morbidity and mortality. The available endovascular technology is associated with specific anatomic considerations and complications. This paper will review the current status of endovascular management of traumatic thoracic aortic injuries.

A 34-year-old woman presented with both coarctation of the thoracic aorta and aneurysm of the superior mesenteric artery. The former was managed by open surgical repair, the latter by stent-graft. This case illustrates the need for facility with both percutaneous and open approaches to diseases of the aorta and its branches.

Objective To compare outcomes between endovascular versus surgical repair of abdominal aortic aneurysms (AAA) in a community hospital setting. Methods A retrospective analysis of all patients undergoing repair of AAA during 2007. Inclusion criteria included stability and anatomic suitability for endovascular repair (EVAR). Data analyzed included comorbidity, length of stay, complications, and cost to the hospital. Results Thirty-one endovascular and 12 open cases fit criteria. There were no significant differences in mortality risk, size of aneurysm, or age between the groups (endovascular 71.6 ± 8 years vs. open 66.7 ± 9 years, P = 0.07). The endovascular group included three patients with contained retroperitoneal rupture, one of whom died secondary to visceral embolization and thrombosis (the only mortality). EVAR was performed with local anesthesia in three and spinal in three cases. Twenty-three cases were performed completely percutaneously. There were no deaths in the surgical group, but four patients experienced major complications. There was no difference between groups in terms of “contribution” costs, but EVAR had significantly greater cost/benefit when measuring “fully loaded” costs (endovascular 4436 ± 7418$ vs. open −1418 ± 6756$, P = 0.02). Endovascular was associated with significantly shorter intensive care unit stay (1.3 ± 0.7 days vs. 2.8 ± 2.1 days, P = 0.001) and overall stay (2.5 ± 2.1 days vs. 7.2 ± 1.6 days, P = 0.001). Conclusions Endovascular of AAA seems to be at least equivalent to open repair in terms of acute outcomes, with much improved cost/benefit predominantly linked to reduced length of stay.

Background. Traumatic rupture of the thoracic aorta (TRA) in the pediatric population is uncommon. Management of TRA in general has evolved to include selective nonoperative and endovascular stent graft approaches, although operative repair remains the standard. Methods. We conducted a retrospective chart review of patients younger than 16 years of age admitted to a single institution between March 1985 and February 2002. Results. Of 160 patients admitted with TRA, 11 were younger than 16 (11.9 +/- 3.5) years of age. Concomitant injuries included closed head injury (5 patients) and acute lung injury (6 patients). All were started on beta-blockers when the diagnosis was suspected. Laparotomy was required in 3 patients and orthopedic procedures in 5 patients. Six underwent operative repair (two primary repairs), with no mortality. Cross-clamp time was 30.4 +/- 2.6 minutes. One patient (operated on without bypass) was partially paralyzed. Two patients were managed nonoperatively, 1 with an intimal arch injury, who on subsequent follow-up has demonstrated healing, and 1 who died of head injury. Three patients were managed by endovascular stent grafts, 2 who died of closed head injury and 1 who at 1-year follow-up has fully recovered. The endovascular stent grafts were placed through the femoral artery in 2 patients and through an iliac conduit in 1 patient. No patient died of rupture. Conclusions. The approach to pediatric TRA should be identical to the adult, with early institution of beta-blockers. Depending on the clinical setting, a spectrum of options should be considered, including operation, nonoperation, and endovascular stent graft, although the choice of the latter must be tempered by the lack of long-term follow-up data. (C) 2003 by The Society of Thoracic Surgeons.

Study Objective: To evaluate the components of commonly used central venous catheter kits with respect to the potential for guidewire-mediated complications during catheter placement.Design: Prospective, nonrandomized, observational study.Setting: Six academic hospitals across the United States.Patients: NoneInterventions: None.Measurements and Main Results: 30 commercially manufactured catheter kits (15 tunneled, 15 nontunneled) were opened and evaluated. The catheter or sheath to be introduced was measured and a corresponding ideal guidewire Length was calculated. The ideal Length was then compared to the actual Length, and differences were tabulated. Wire tip configuration and the presence and pattern of distance markings were recorded and, in conjunction with the catheter and wire Length discrepancies, were used to grade the relative risk of introducing excess guidewire during catheter placement. Of 30 kits evaluated, 14 (46.7%) had guidewires more than 20 cm longer than necessary. The mean excess wire length was 15 cm (range: 8 to 55 cm) and did not differ significantly between tunneled and nontunneled catheter kits. Only 10 kits (33.3%) had distance markings of any type, and there was no standardization among them; none corresponded to previously published recommendations. There was potential risk of excess wire introduction in 18 catheter kits, of which seven were nontunneled devices designed for bedside placement.Conclusions: The design of commonly employed central venous access catheter kits is such that there is a mismatch between guidewire and catheter length and a general lack of guidewire markings. We believe that these designs may predispose to the introduction of excess guidewire and result in guidewire-mediated complications during catheter placement. This risk can likely be reduced by matching the guidewires to the devices placed over them and by standardizing guidewire distance markings. (C) 2003 by Elsevier Inc.

Widening of the mediastinum on chest radiography is widely promoted as a useful criterion for detecting aortic injury. We sought to determine the reliability, sensitivity, and specificity of this sign. The initial chest radiographs from 30 subjects with aortic injury and 47 controls were independently reviewed by six radiologists, who were blinded to diagnosis. The radiologists were asked to decide whether the mediastinum was normal or not normal, as well as whether the mediastinum was widened. Agreement, sensitivity, and specificity were assessed. Agreement for overall assessment of the mediastinum was substantial (kappa = 0.64). Individual radiologists had sensitivity varying from 0.77 to 0.97 and specificity varying from 0.62 to 0.89. For "widening" of the mediastinum, agreement was moderate (kappa = 0.49). "Widening" was less sensitive than the radiologists' overall impression (P = 0.01), varying from 0.50 to 0.83, but no difference was detected in specificity (P = 0.36), varying from 0.81 to 0.94. Mediastinal width has unacceptable sensitivity for predicting aortic injury, with substantial inter-reader variability. Medical education has ingrained the widely promoted concept of mediastinum widening, which may be misleading.

A patient with superior vena cava (SVC) occlusion presented with severe ascites and urgent transjugular intrahepatic portosystemic shunt (TIPS) was requested. The patient had a chronically occluded SVC. An alternative to classic TIPS was employed using CT guidance to traverse the left portal vein to the inferior vena cava with a small gauge needle. Fluoroscopic guidance was then used to snare a wire placed through the needle and then work from the femoral vein to create a portocaval shunt that passed through the caudate lobe. This procedure was a technical success and improved the patient's ascites.

Purpose: Comparative evaluation of the biological effects of a silicone-covered stent versus a bare-metal stent, in an animal model.

The etiology of acute intraabdominal bleeding is often unclear at the time emergent arteriography is performed. During localization and embolization, the arteriogram may suggest the diagnosis of vasculitis. However, controlling the bleeding remains the priority. Connective tissue diseases such as Ehlers-Danlos syndrome (EDS) may also cause bleeding and mimic vasculitis and must be included in the differential diagnosis. We present such a case in which the initial findings were misleading.

Purpose: To compare patency rates of transjugular intrahepatic portosystemic shunts (TIPS) after placement of long-medium Palmaz stents or Wallstents.

Purpose To evaluate the potential benefits of placing a polytetrafluoroethylene (PTFE)-covered stent-graft during initial creation of a transjugular intrahepatic portosystemic shunt (TIPS) in clinical practice. Materials and Methods De novo TIPS were created with a PTFE stent-graft in four male and four female patients with symptomatic portal hypertension awaiting liver transplant. Their ages ranged from 35 to 62 (mean, 47) years. Patients were followed with TIPS ultrasound (US) and/or venography until liver transplantation or death; one remains under active study. Six recovered specimens underwent gross and microscopic evaluation. Results All TIPS placements were successful. Six shunts were primarily patent, with a mean patency of 289 days, through completion of the study. Five were found to be patent at transplant and one was found to be patent at autopsy. Explant evaluation revealed a smooth, thin layer of neointima and exclusion of biliary secretions. Three patients developed a total of four stenoses (one tandem lesion) during follow-up, leading to revision in two patients. Mean primary and total patency in these patients was achieved after 279 and 463 days, respectively. A previously occult moderate stenosis was detected after explant in another patient. Only one (nonsignificant) stenosis clearly developed in an area covered by PTFE. Conclusion Placement of a de novo PTFE stent-graft during TIPS creation is feasible and may extend primary shunt patency. Appropriate positioning of the stent-graft is critical.

OBJECTIVE The purpose of this study was to evaluate whether a valved peripherally inserted central catheter (PICC) design would result in a lower incidence of occlusion, infection, and malfunction than a clamped catheter. SUBJECTS AND METHODS Three hundred sixty-two study patients (233 men, 129 women; mean age, 44 years) were randomized to receive a clamped (n = 182) or valved (n = 180) 5-French single-lumen PICC. Catheters were placed under fluoroscopic (n = 331) or sonographic guidance (n = 31). The valved PICC was flushed with saline solution, and the clamped PICC was flushed with a heparin-saline solution. All patients were prospectively followed up at least weekly for catheter status and complications. RESULTS Percutaneous placement with the catheter tip in the central veins was successful in 99% of patients. Mean dwell time was 34 days. Twenty-six occlusive or infectious complications occurred in the clamped catheter group and 12 in the valved catheter group (p = .02). The clamped and valved catheter groups had 13 and five occlusions, respectively (p = .06), and 12 and five catheter-related blood stream infections, respectively (p = .09). Most occlusions (68%) were treated successfully with urokinase, and site infection or sepsis was treated by catheter removal. CONCLUSION We found a statistically significant difference in the complication rate for the valved PICC compared with the clamped PICC. With the valved PICC, occlusion and infection were reduced, and patients having these catheters did not require heparin flushes.

PURPOSE:To evaluate a new 19-gauge blunt-tipped, side-cutting, single throw transjugular biopsy needle for transvenous kidney biopsies.MATERIALS AND METHODS:Transjugular transvenous kidney biopsies were performed with a modified 70-cm biopsy needle utilizing fluoroscopic guidance in nine swine. Three tissue specimens were obtained with four biopsy device passes in five animals and three biopsy device passes in four animals. Renal arteriography and venography were performed immediately before and after renal biopsy. Five animals were killed immediately after biopsy. Four animals were allowed to recover and underwent arteriography and venography prior to being killed, which varied from 1 to 6 weeks. Gross and histologic examinations of the biopsied kidney were performed after euthanasia. A pathologist reviewed all biopsy specimens for quality based on the number of glomeruli present.RESULTS:Results of immediate and delayed arteriography and venography were normal in all cases. Histologic evaluation of all biopsy specimens demonstrated a range of two to 13 glomeruli per sample (mean, 6.5), with successful acquisition of the cortex. In one animal killed immediately after biopsy, a small subcapsular hematoma was present.CONCLUSION:The 19-gauge, side-cut biopsy needle with a blunt-tip stylet proved to be efficacious for obtaining renal cortical samples in right swine kidneys via a transjugular approach.

Purpose: To evaluate shunt patency after placing a new polyurethane-coated Dacron-covered spiral Z stent-graft to create a transjugular intrahepatic portosystemic shunt (TIPS).Methods: TIPS stent-grafts were placed in six young swine, using polyurethane-coated, Dacron-covered spiral Z stent-grafts. Animals were followed weekly by transhepatic portal venography until shunt occlusion or up to 6 weeks, then were sacrificed for gross and histologic evaluation.Results: Five of six TIPS stent-grafts were found to be occluded by 3 weeks and none were patent at 6 weeks. Histologic evaluation demonstrated a marked foreign body reaction with superimposed thrombosis occluding the graft lumen.Conclusion: Polyurethane-coated Dacron-covered stent-grafts do not improve TIPS patency.