Mural aortic thrombus is a challenging clinical problem with significant potential complications. Particularly precarious are situations with involvement of the visceral segment of the aorta. We describe a technique for percutaneous thrombectomy of mural aortic thrombus using intravascular ultrasound to guide an angled mechanical thrombectomy catheter in conjunction with a continuous aspiration system (Indigo mechanical thrombectomy system; Penumbra, Alameda, Calif). Use of this technique in three patients with challenging cases of mural aortic thrombus is discussed. All patients were treated successfully and without complication using this technique.
Brief Reports should be submitted online to www.editorialmanager.com/ amsurg. (See details online under ''Instructions for Authors''.) They should be no more than 4 double-spaced pages with no Abstract or sub-headings, with a maximum of four (4) references. If figures are included, they should be limited to two (2). The cost of printing color figures is the responsibility of the author.In general, authors of case reports should use the Brief Report format.
Dysphagia Lusoria is a condition when aberrant right subclavian artery (ARSA) causes esophageal compression. We report 2 cases of Dysphagia Lusoria treated by hybrid endovascular technique which included subclavian to carotid transposition and embolization of origin of ARSA. By using this technique, we avoided the need for thoracotomy. Both patients had complete symptom relief without any surgery related complication.
We report a case of a 17-year-old male with Behcet’s disease (BD) with giant celiac artery aneurysm and impending rupture. Over the past 8 weeks, patient began having intermittent back and abdominal pain that worsened and became persistent over the past few days. This was accompanied by anorexia and non-bilious vomiting. Computed tomography angiogram (CTA) demonstrated a wide neck large celiac artery aneurysm (60 mm diameter). Endovascular repair of the aneurysm was performed using stent graft of the aorta and transcatheter coil embolization of the aneurysm sac. Technical success was confirmed by interruption of flow in the aneurysm, and preservation of distal native circulation at the conclusion of the procedure. One-week post-embolization, a CTA demonstrated complete thrombosis of the aneurysm. On follow-up CTA at 3, 6, and 12 months after embolization, the aneurysm has completely thrombosed and decreased in size to 24 mm. Patient remains asymptomatic till date.
Background
Neuraxial blocks is the recommended mode of analgesia and anesthesia in parturients with Coronavirus 19 (COVID-19). There is limited data on the hemodynamic responses to neuraxial blocks in COVID-19 patients. We aim to compare the hemodynamic responses to neuraxial blocks in COVID-19 positive and propensity-matched COVID-19 negative parturients.
Methods
We conducted retrospective, cross-sectional case–control study of hemodynamic changes associated with neuraxial blocks in COVID-19 positive parturients in a Tertiary care academic medical center. Fifty-one COVID-19 positive women confirmed by nasopharyngeal reverse transcription–polymerase chain reaction (RT-PCR), were compared with propensity-matched COVID negative controls (n = 51). Hemodynamic changes after neuraxial block were recorded by electronic medical recording system and analyzed using paired and unpaired T- test and Wilcoxon-Mann–Whitney Rank Sum tests. The primary outcome was ≥ 20% change in MAP and HR after neuraxial block placement.
Results
In the epidural group, 7% COVID-19 positive parturients had > 20% decrease in mean arterial pressure (MAP) from baseline compared to 15% COVID-19 negative parturients (P = 0.66). In the spinal group, 83% of COVID-19 positive parturients had a decrease in MAP more than 20% from baseline compared to 71% in control (P = 0.49). MAP drop of more than 40% occurred in 29% COVID positive parturients in the spinal group versus 17% in COVID-19 negative parturients (P = 0.5465). In COVID-19 positive spinal group, 54% required vasopressors whereas 38% in COVID-19 negative spinal group required vasopressors (P = 0.387). We found a significant correlation between body mass index (BMI) > 30 and hypotension in COVID ( +) parturient with odds ratio (8.63; 95% CI-1.93 – 37.21) (P = 0.007).
Conclusion
Incidence and severity of hypotension after neuraxial blocks were similar between COVID-19 positive and COVID-19 negative parturients. BMI > 30 was a significant risk factor for hypotension as described in preexisting literature, this correlation was seen in COVID-19 positive parturients. The likely reason for parturients with BMI > 30 in COVID negative patients not showing similar correlation, is that the sample size was small.
Major injury of the innominate artery is traditionally treated with an open repair which is technically challenging, associated with large volumes of blood loss and prolonged operative times. Endovascular treatment with covered stent placement across the injury is an attractive alternative. However, placement of a single covered stent across the innominate artery bifurcation into one of its distal branches will not prevent bleeding because of retrograde perfusion from the unstented branch distal to the bifurcation. Here, we report a case of successful endovascular repair of one such injury involving the innominate artery bifurcation with ongoing extravasation into the mediastinum. The injury was successfully treated by utilizing 2 balloon-expandable covered stents placed in kissing fashion from the innominate artery into both of its distal branches. This technique of parallel covered stent placement across a bifurcation could effectively repair bifurcation injuries while maintaining patency of both distal branches.
Background Percutaneous Inferior Venacava (IVC) filter retrieval can be challenging when the filter is grossly angulated, embedded in the wall or penetrates through the IVC. When conventional filter removal technique fails, the use of advanced retrieval techniques often improves the chances of percutaneous filter retrieval. These techniques, however, are associated with a high rate of complications. Methods We report a case of 26-year-old female who had IVC filter placed on postpartum day 4. Attempted percutaneous filter retrieval 3 weeks later with loop snare technique and endobronchial forceps assisted filter removal technique resulted in gross filter deformity, malposition, and IVC perforation. Result Open IVC filter removal was performed with midline laparotomy and cavotomy with lateral venorrhapy. The deformed filter along with adherent thrombus was completely removed. The patient had an uneventful recovery with no immediate or long-term complications. Conclusion Use of advanced endovascular IVC filter retrieval techniques could result in serious complications like filter fracture, migration and IVC perforation. Since excessive tilt of the filter at the time of placement often results in difficult retrieval, it is important to ensure proper deployment of the filter with minimal tilt. If encountered with excessively tilted or embedded filter, one should refrain from excessive manipulation of the filter and consider open filter removal.
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