An 82-year-old man with a history of endovascular repair for ruptured abdominal aortic aneurysm 6 years ago presented with a type II endoleak and enlarging sac. He had successful transabdominal direct sac puncture embolization but developed fever 2 days postoperatively. Contrast-enhanced computed tomography showed a rim-enhancing collection, and sac aspiration was positive for enteric organisms, confirming endograft infection. The patient underwent graft explantation and neoaortic reconstruction using superficial femoral veins. Three months postoperatively, computed tomography showed complete resolution of fluid collection and no signs of graft infection. This report illustrates direct puncture embolization complicated by endograft infection from enteric bacteria.
Objective: Vascular specialists are increasingly being requested to perform carotid endarterectomy (CEA) after intravenous thrombolysis (IVT) for stroke patients, raising concerns about hemorrhagic complications. Few case series and registry reports have assessed the question, focusing on comparison with symptomatic patients. The goal was to evaluate the hemorrhagic and overall outcomes of patients undergoing CEA after IVT and to compare them with a similar population. Methods: We retrospectively analyzed the data of 170 consecutive patients who have undergone CEA after stroke in our center from January 2011 to December 2016; 26 (15.1%) of them had undergone previous IVT. A comparative analysis between the non-IVT and the IVT groups was performed. Overall time between diagnosis of stroke and referral to a vascular specialist was also analyzed. Results: Age, sex, and cardiovascular comorbidities were similar in both groups. Median time between IVT and CEA was 8 days (Q1-Q3, 5-15 days), with nine (41%) patients undergoing CEA <7 days after IVT. There were two (1.4%) intracranial hemorrhages in the non-IVT group vs one (3.8%) in the IVT group (P ¼ .950). The overall combined stroke and death rate was 5.3%, with 4.9% in the non-IVT group vs 7.7% in the IVT group (P ¼ .913). Postoperative cervical hematoma requiring reoperation occurred similarly in both groups (2.1% vs 3.8%; P ¼ 1). Median modified Rankin score at 30 to 90 days of follow-up was 1 (Q1-Q3, 0-2), and it was similar in both groups (P ¼ .156). Median time between diagnosis of stroke and referral to a vascular specialist was higher for patients in peripheral centers (4 days; Q1-Q3, 2-7 days) compared with university vascular centers (1 day; Q1-Q3, 0-3 days; P < .001). Conclusions: In this retrospective analysis, CEA after IVT showed similar hemorrhagic and overall outcomes compared with the overall stroke-CEA population.
Background: Worldwide, the majority of kidney failure patients are treated by hemodialysis. The demand for vascular access surgery is increasing rapidly because of the continuing expansion of this population. A reliable access to the circulation for hemodialysis is essential. A proportion of hemodialysis patients exhaust all options for permanent arteriovenous (AV) access (fistula or graft) in both upper extremities. AV thigh grafts are a potential vascular access option in hemodialysis patients who have exhausted all upper limb sites. This paper reports our experience with vascular access in the thigh.Methods: We performed a retrospective review of the University Health Network's Division of Nephrology dialysis access database to identify all thigh AV access grafts placed between November 1995 and November 2015. Electronic medical records were then reviewed to determine demographic and clinical information. The charts were examined for subsequent surgical or endovascular procedures performed on the accesses. The patency of each thigh AV access was determined from the time of surgical creation placement, and the reason for failure was documented.Results: A total of 41 hemodialysis patients received 47 thigh AV accesses for hemodialysis vascular access during the study period. The average age of the cohort was 46 years (range, 13-79 years). The majority of the patients (53.6%; n ¼ 22) were female, and the majority of AV accesses (55.3%; n ¼ 26) were placed in the left leg. Three patients were lost to follow-up; but of the remaining 38 patients, the average patency for the grafts (n ¼ 44) was 1130.6 days (range, 0-4745 days). Thirty-six percent (n ¼ 17) of the grafts required surgical revision to eradicate infection or to maintain patency. Seventeen of 44 grafts (38.6%) served as definitive hemodialysis AV access during the patient's lifetime of dialysis. The majority failed because of infection 43.1% (n ¼ 19) or thrombosis 13.6% (n ¼ 6).Conclusions: AV thigh grafts are used infrequently, but they have a good patency. However, they require frequent revisions and have a high infection rate resulting in the ultimate loss of the access in 43.1% of cases. Despite this, an acceptable proportion of leg grafts provide durable access for the dialysis lifetime of the patient.
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