Blue toe syndrome: treatment with intra-arterial stents and review of therapies

PURPOSE

To determine if intra-arterial stent placement can adequately treat lesions producing microemboli to the lower extremities.

MATERIALS AND METHODS

During a 6.5-year period, 15 patients presenting with blue toe syndrome had 16 presumed embolic lesions treated with intra-arterial stents. These patients were evaluated during routine clinical follow-up during a 6-month period. This evaluation included physical and noninvasive arterial examinations. When patients could not return for follow-up, hospital, clinical, vascular laboratory, and radiology records were reviewed to assemble the appropriate information. Outcomes included symptoms of recurrent emboli, amputation, and death.

RESULTS

Treated embolic lesions included two aortic stenoses, three bilateral iliac artery stenoses, nine unilateral iliac artery stenoses (one patient received separate treatment of unilateral iliac lesions), and two superficial femoral artery stenoses. Patients were followed-up for a mean of 18 months. Eight of 15 patients (53%) were improved or stable without complications. There were eight negative outcomes experienced in seven patients. Three patients (20%) were deceased at follow-up. Four patients (27%) had undergone amputation; one transmetatarsal amputation and three below-the-knee amputations. Only one of these was related to progressive disease in the treated extremity (7%). One patient (7%) experienced recurrent embolic symptoms. Stents were patent in all patients.

CONCLUSION

Patients with blue toe syndrome are at high risk of limb loss and mortality despite treatment. Intra-arterial stent placement provides an alternative to standard surgical treatment. Further studies are needed to define the optimum therapy.

Isolation of the left innominate artery in an elderly patient without congenital heart disease

We report a rare anomaly consisting of a right aortic arch with an isolated left innominate artery in an elderly man without congenital heart disease.

Suprarenal vena caval filter placement: follow-up of four filter types in 22 patients

PURPOSE

To determine if suprarenal placement of inferior vena cava (IVC) filters is associated with renal dysfunction or other complications.

MATERIALS AND METHODS

Case files of all patients with suprarenal vena caval filter placement since 1985 were reviewed for clinical and biochemical evidence of renal dysfunction and renal vein thrombosis. The occurrence of associated complications, including IVC occlusion, filter fracture, device migration, and recurrence of pulmonary embolism was also recorded.

RESULTS

Twenty-two (2.9%) of 764 IVC filters were implanted above the renal veins: titanium Greenfield filter modified hook (TGF-MH) (n = 16), LGM type I (n = 2), LGM type II (n = 2), and Bird's Nest (BN) type I (n = 2). Reasons for suprarenal filter placement included thrombus to the level of the renal veins (n = 9), failure or poor position of the infrarenal filter (n = 6), pregnancy or intent of pregnancy (n = 4), and the malpositioning of BN filters above the renal veins (n = 2). A single patient demonstrated evidence of transient renal dysfunction. Pulmonary embolus was found at autopsy in one patient. Abdominal radiographs were obtained at follow-up of 18 patients and demonstrated a 2 cm or more migration of the filter in five patients (27.7%). This rate of migration was significantly different from the 3% migration rate reported by the authors' institution in the follow-up of 320 infrarenal IVC filters. There was one filter fracture (5.5%.) and penetration of the IVC occurred in one patient (5.5%).

CONCLUSION

Follow-up indicates suprarenal IVC filter placement is safe, and no evidence of permanent renal dysfunction after placement was found. Filter migration was the most frequent complication, but no clinical sequelae were noted with these patients.

Snare retrieval of migrated ventriculoatrial shunt

Among the numerous complications of ventriculoatrial shunting, discontinuity and migration of a catheter fragment into the heart or pulmonary arteries is only rarely encountered. Percutaneous snare retrieval of shunt tubing from the pulmonary arteries is described in a patient presenting with signs of shunt malfunction.

Evaluation of a new percutaneous stainless steel Greenfield filter

PURPOSE

To evaluate a new percutaneous Greenfield filter with an alternating hook design and over-the-wire delivery system.

MATERIALS AND METHODS

The alternating hook stainless steel Greenfield filter was evaluated in a prospective clinical trial between March 10, 1994, and January 27, 1995. Filters were placed in 75 patients in nine clinical centers and follow-up with radiographs and ultrasound scans was carried out at 30 days.

RESULTS

Clinical trial results revealed successful placement in all patients. There were four cases of filter limb asymmetry (5.3%) without clinical sequelae, with one incidence of failure to span the cava. No significant migration was found. There were no clinically suspected pulmonary emboli, but one instance of probable caval penetration (1.7%) did occur. Caval occlusion was documented in three patients (5%).

CONCLUSION

The percutaneous stainless steel Greenfield filter provides ease of insertion and improved deployment while maintaining the high standards of efficacy and safety associated with the standard and titanium Greenfield filters.

Azotemia: gadopentetate dimeglumine as contrast agent at digital subtraction angiography

In an azotemic patient with suspected renal artery stenosis, undiluted gadopentetate dimeglumine was administered in an aortic bolus to provide contrast at digital subtraction angiography of the aorta and renal arteries. The contrast material (5 mmol/mL) was power injected (rate, 15 mL/sec; total dose, 30 mL). Selective renal arteriography was also performed with 5 mL of undiluted gadopentetate dimeglumine hand injected into each renal artery (total dose, 40 mL). The patient tolerated the procedure without complication or worsening of renal function, and diagnostic angiographic images were obtained.

Primary Clostridium septicum aortitis: a rare cause of necrotizing suprarenal aortic infection. A case report and review of the literature

A 74-year old woman sought medical attention for general symptoms of nausea, vomiting, and back pain. A computed tomographic scan showed gas in the wall of the descending thoracic and suprarenal aortas. Emergency thoracoabdominal exploration revealed a necrotizing infection of the thoracic aorta extending to the origin of the celiac axis. After surgery Clostridium septicum was identified in tissue culture. Surgical management consisted of in-situ graft replacement of the thoracoabdominal aorta. Three months later, a pseudoaneurysm developed at the distal anastomosis. The patient refused further surgery and died 3 days later. The cause of death was presumed to be a ruptured mycotic aneurysm as a result of recurrent C. septicum infection. The relationship of C. septicum with occult gastrointestinal and hematologic malignancy has been documented. This patient represents the 10th reported case of C. septicum arteritis. Including the nine previous case reports of C. septicum arteritis, the mortality rate is 70%. When evaluating a patient with a mycotic aneurysm or aortitis, C. septicum should be considered. If it is found, a search should be carried out for an associated gastrointestinal or hematologic malignancy. Surgical repair should include extraanatomic revascularization and wide debridement of the infected field. Consideration should be given to lifelong antimicrobial therapy for this potentially fatal infection.

Agenesis of the internal carotid artery with intercavernous anastomosis

We report a case of unilateral agenesis of the internal carotid artery with intercavernous anastomosis, a rare development anomaly. MR and carotid ultrasound, in association with clinical awareness, can be used to diagnose this condition.

Surgical treatment of superior mesenteric artery dissecting aneurysm and simultaneous celiac artery compression

Spontaneous dissections of visceral arteries are rare, but when they do occur, they most commonly involve the superior mesenteric artery (SMA). We present a case of intestinal ischemia caused by a spontaneous dissection of the SMA in a patient with simultaneous celiac artery occlusion. The patient was a 45-year-old woman who presented with intestinal angina of sudden onset. Arteriography revealed the classic findings of SMA dissection and occlusion of the celiac artery. The patient underwent repair of both visceral vessels and made a full recovery. The 18 previously reported cases of isolated, spontaneous dissection of the SMA are reviewed. No previous case has been associated with celiac compression syndrome. The reported experience with symptomatic dissections of the SMA would suggest that prompt surgical repair is indicated and yields excellent results.

Percutaneous inferior vena caval filters: follow-up of seven designs in 320 patients

Three hundred twenty-four percutaneous inferior vena caval (IVC) filters of different designs were placed in 320 patients from April 1985 through June 1992. No acute mortality or substantial morbidity was attributed to filter placement. Radiologic or pathologic follow-up data were obtained in 227 (71%) patients (230 filters); clinical follow-up data only were obtained in 50 (16%) patients (50 filters). One hundred twenty (43%) patients died; post-filter-placement pulmonary emboli (PE) were related to the cause of death in eight. At IVC filter imaging studies, 26 of 137 (19%) filters demonstrated caval thrombus; 12 of 132 (9%) filters had delayed penetration through the IVC wall of greater than 3 mm; 13 of 230 (6%) filters migrated more than 1 cm; and five of 230 (2%) filters had fracture of a strut or leg. Deep venous thrombosis (DVT) at the insertion puncture site or in the lower extremity was noted in 26 of 117 (22%) cases of filter placement. Among patients without imaging studies, clinical suspicion of complications included PE in four patients, IVC thrombus in 14 patients, and lower-extremity DVT in 10 patients. Long-term clinical and radiologic follow-up of all IVC filters is indicated due to the relatively high prevalence of some complications.

Thromboembolism in patients undergoing thoracotomy

To determine the incidence of thromboembolism in relation to thoracotomy, 77 patients undergoing pulmonary resection were prospectively studied up to 30 days postoperatively for deep venous thrombosis and pulmonary embolism. Overall, 20 of 77 patients (26%) had thromboembolic events during their hospitalization. Four deep venous thromboses and 1 pulmonary embolism were detected in 5 of 77 patients preoperatively for an incidence of 6%. Postoperative thromboembolism was detected in 15 of 77 (19%): deep venous thrombosis in 11 (14%) and pulmonary embolism in 4 (5%). No postoperative thromboembolisms occurred in the 17 patients receiving preoperative aspirin or ibuprofen, whereas they did occur in 25% of the remainder (15/60). Thromboembolism after pulmonary resection was more frequent with bronchogenic carcinoma than with metastatic cancer or benign disease (15/59 [25%] versus 0/18 [0%]; p < 0.01), adenocarcinoma compared with other types of carcinoma (11/25 [44%] versus 4/34 [12%]; p < 0.0004), large primary lung cancer (> 3 cm in diameter) compared with smaller lesions (9/19 [47%] versus 6/40 [15%]; p < 0.0001), stage II compared with stage I (7/14 [50%] versus 7/34 [21%]; p < 0.04), and pneumonectomy or lobectomy compared with segmentectomy and wedge resection (14/49 [29%] versus 1/28 [4%]; p < 0.005). Three of 4 patients with thromboembolism detected preoperatively had operation within the previous year. Postoperative pulmonary embolism was fatal in 1 of 4 (25%) and accounted for the one death. These results suggest patients undergoing thoracotomy for lung cancer, especially adenocarcinoma, should be considered for thromboembolic prophylaxis.

Ultraviolet laser excitation source

A new intense ultraviolet light source has been developed from an array of hypocycloidal pinch (HCP) devices. The basic unit of the array is constructed with three disk electrodes and is capable of producing dense plasmas at temperatures up to 10,000,000 K. Very high input power levels to the array are possible without significantly shortening its useful life, in strong contrast with conventional xenon flashlamps. The new light source, when operated with Ar and Xe gas mixtures at high pressures (~5 x 10(4) Pa), produced a light output of over 100 MW in the near-UV spectral range and successfully pumped an iodine photodissociation laser at 1.315 microm. A xenon recombination laser at 2.027 microm was also pumped in the HCP array.