Emergency management of iatrogenic arterial injuries with a low-profile balloon-expandable stent-graft: Preliminary results

Stent Graft Placement for Injured Visceral Artery

Injury of the visceral artery is a potentially fatal complication of iatrogenic procedures, trauma, and tumors. A stent graft can achieve rapid exclusion of the injured arterial portion and minimize the risk of ischemic complications by preserving arterial flow to organs. Although various types of stent grafts are available worldwide, Viabahn has only been approved for visceral arterial injury in Japan. The reported technical and clinical success rates, including cases with injured pelvic or thoracic arterial branches, are 80%-100% and 66.7%-100%, respectively. Severe ischemic complications are rare; however, fatal ischemia occurs when the stent graft is immediately occluded. The necessity of antiplatelet therapy is controversial, and a target artery diameter ≤ 4 mm is a significantly higher risk factor of stent-graft occlusion.

Coronary stent-graft use to salvage a juxta-anastomotic arterial rupture complicating a case of radio-cephalic fistuloplasty

Background

Stenosis is a common complication of haemodialysis arteriovenous accesses. Endovascular approaches with percutaneous transluminal fistuloplasty have largely replaced open surgical approaches as first line treatment. Vessel rupture is an uncommon complication of fistuloplasty and most reports describe venous rupture. Stent-graft deployment can salvage this, however, its use requires careful assessment of the distal vasculature. Arterial rupture with fistuloplasty has rarely been described in the literature. This is a novel case describing the use of a BeGraft coronary stent-graft to manage juxta-anastomotic arterial rupture and pseudoaneurysm complicating fistuloplasty.

Case presentation

A 77 year old female with end stage renal failure secondary to systemic amyloid light chain type amyloidosis was referred for a suspected radio-cephalic arteriovenous fistula stenosis after difficulty cannulating with poor flow during dialysis and clinical reduction in the fistula thrill. Both Doppler ultrasound and intravenous fistulography confirmed a venous stenosis 2 cm distal to the anastomosis. The stenosis was treated by fistuloplasty, however, this was complicated by a rupture of the juxta-anastomotic arterial segment intraoperatively. Intermittent balloon tamponade was used to minimise extravasation although a pseudoaneurysm formed within the damaged arterial segment. The patient’s distal neurovascular status was assessed using the Barbeau test and we sonographically confirmed adequate retrograde arterial flow via a complete palmar arch directing blood from the ulnar artery. After discussion with the renal transplant team, a 4 mm BeGraft coronary stent-graft was deployed to control haemorrhage and bypass the pseudoaneurysm until adequate haemostasis and fistula flow was achieved. Follow-up 3 months post-procedure reported the patient continued with haemodialysis using the stented fistula with no further complications.

Conclusions

To our knowledge, this is the first case report describing the application of BeGraft coronary stent-grafts to salvage fistuloplasty of a radio-cephalic arteriovenous fistula stenosis complicated by juxta-anastomotic arterial rupture and pseudoaneurysm formation. We demonstrate the safety and short-term efficacy of this technology.

Iatrogenesis in the context of residential dementia care: A concept analysis

Background and Objectives

This concept analysis aims to explore iatrogenesis within the context of residential dementia care and to distinguish this phenomenon from similar phenomena, such as abuse and inadvertent harm.

Research Design and Methods

Walker and Avant’s method for concept analysis was used to define critical attributes of iatrogenesis within residential dementia care, and to explore antecedents and consequences of its occurrence. A review of the literature about iatrogenesis in the context of residential dementia was conducted across 4 electronic databases. Texts about iatrogenesis in surgery, medicine, social work, psychology, and other relevant disciplines were also reviewed to provide additional context for the concept.

Results

Iatrogenesis takes a unique form in residential dementia care. The final definition of the concept proposed in this article is habituated, forceful, hands-on care provided to residents who exhibit responsive behaviors that result in emotional, physical, spiritual, social harm, and/or gradual functional decline, that is provided with the intention of supporting the resident’s safety and dignity.

Discussion and Implications

The definition of iatrogenesis proposed in this article is an initial step toward developing evidence-based practice for the provision of nonconsensual assistance in residential dementia care. A theoretical definition like the one proposed in this article may serve as a starting point for the operationalization of the concept, which would promote future empirical research into staff and residents’ experiences of health care-inflicted harms in this context. Theoretically, it contributes to critical conversations about the narratives, myths, and misperceptions that facilitate the provision of nonconsensual care.

Applying Principles of Regenerative Medicine to Vascular Stent Development

Stents are a widely-used device to treat a variety of cardiovascular diseases. The purpose of this review is to explore the application of regenerative medicine principles into current and future stent designs. This review will cover regeneration-relevant approaches emerging in the current research landscape of stent technology. Regenerative stent technologies include surface engineering of stents with cell secretomes, cell-capture coatings, mimics of endothelial products, surface topography, endothelial growth factors or cell-adhesive peptides, as well as design of bioresorable materials for temporary stent support. These technologies are comparatively analyzed in terms of their regenerative effects, therapeutic effects and challenges faced; their benefits and risks are weighed up for suggestions about future stent developments. This review highlights two unique regenerative features of stent technologies: selective regeneration, which is to selectively grow endothelial cells on a stent but inhibit the proliferation and migration of smooth muscle cells, and stent-assisted regeneration of ischemic tissue injury.

Life-threatening subclavian artery bleeding following percutaneous coronary intervention with stent implantation: A case report and review of literature

BACKGROUND

Vascular complications of transradial percutaneous coronary intervention (PCI) are rare and usually occur at the access site below the elbow. Life-threatening vascular complications during transradial PCI therapy, such as vessel perforation and dissection in the brachiocephalic, subclavian, internal mammary, and thyrocervical arteries, are rarely reported. Subclavian artery bleeding is a potentially serious complication of vascular interventional procedures leading to tracheal obstruction, hemothorax, respiratory failure, hemorrhagic shock, and death if not diagnosed early and treated promptly.

CASE SUMMARY

A male patient with typical angina pectoris underwent coronary angiography and stent implantation. During the procedure, the patient felt pharyngeal pain and tightness, which we mistook for myocardial ischemia. After PCI, swelling in the right neck and supraclavicular area was observed. The patient experienced dyspnea, emergency endotracheal intubation was performed, and then a sudden drop in blood pressure was observed. Ultrasound and contrast-enhanced computed tomography scans demonstrated a cervical hematoma severely compressing the trachea due to subclavian artery bleeding. Brachiocephalic angiography revealed a vascular injury site at the root of the right subclavian artery at the intersection of the right common carotid artery. A covered stent was deployed to the right subclavian artery with successful sealing of the perforation, and a bare stent was implanted in the junction of the right common carotid and brachiocephalic arteries to prevent obstruction of blood flow to the brain.

CONCLUSION

Subclavian artery bleeding is a lifethreatening complication of PCI. Early prevention, rapid recognition, and prompt treatment may improve the prognosis.