Native Arteriovenous Fistula Creation in Patients With Continuous Flow Left Ventricular Assist Devices: A Case Report and a Narrative Review

Worsening of kidney function after left ventricular assist device (LVAD) implantation is common, and many patients reaching end-stage kidney disease require long-term dialysis. Permanent vascular access in a patient with LVAD remains a clinical dilemma. There is a theoretical concern about the maturation of the arteriovenous fistula in a patient with LVAD due to the absence of a pulsatile flow in these patients. We described a case of successful creation of a left brachial-cephalic AVF in a patient with continuous flow LVAD (Abbott's HeartMate 3TM), which was used for dialysis without issue.

Midline Mandibulotomy for large Carotid body tumors: A valuable approach

In the present case, a 41-year-old male patient had reported a large swelling on the right side of his neck that had been radiographically diagnosed as a carotid body tumor. The tumor extended toward the right thyroid lobe, deep to the parapharyngeal space and cranially to the base of the skull. The clinical and medical imaging findings confirmed the diagnosis. Because of the large size of the tumor (50 mm × 48 mm × 85 mm), extent of involvement, and hypervascularity, surgical excision by midline mandibulotomy was chosen as the treatment approach. Midline mandibulotomy is a very good approach for large tumors with extensive involvement of the surrounding tissues, especially tumors with great medial and cephalic extension.

Renal-inferior vena cava fistula complicating laparoscopic cholecystectomy causing heart failure repaired endovascularly, a case report and literature review

INTRODUCTION

Renal-caval Arterio-venous fistulas are rare entity which can be acquired, idiopathic or congenital. Laparoscopic cholecystectomy complicated by arteriovenous fistula formation is extremely rare and often go unnoticed. High output heart failure can occur as a consequence of such high flow fistulas. Repair can be done through open or endovascular approach with the latter being effective and less invasive. Repair can result in resolution of symptoms and improvement of heart function.

CASE PRESENTATION

We report a 43-year old female who developed an iatrogenic renal-caval fistula following laparoscopic cholecystectomy, that was complicated by intraoperative bleeding. She presented with worsening high output cardiac failure a year post-operative. Due to past history of Cor-triatriatum surgical repair -a congenital heart disease-, the diagnosis of renal arteriovenous fistula remained insidious. The fistula was diagnosed during cardiac catheterization in an attempt to diagnose her rapidly decompensating heart failure, and repaired successfully by endovascular repair.

DISCUSSION

To our knowledge, there are only a few reports in literature describing iatrogenic renal artery-caval fistulas in association with laparoscopic cholecystectomy. Such high flow fistulas can result in a significant, potentially life threatening physiologic impairment. The case was managed by endovascular approach resulting in return to baseline cardiac function and resolution of symptoms.

CONCLUSIONS

Renocaval arteriovenous fistulas are extremely rare to complicate laparoscopic cholecystectomy. It might go unnoticed, but may present with decompensated heart failure. It can be reversed by early recognition of symptoms, and diagnosis. High index of suspicion is a key, and endovascular modality is excellent treatment approach.

Conservative management of asymptomatic lately embolized amplatzer atrial septal occluder device to the supraceliac abdominal aorta: case report and the literature review

Atrial septal defects of a single Secundum with favorable anatomy and margins are commonly treated with septal occluder devices. Device embolization is a well-known rare and serious complication of transcatheter structural heart interventions. Percutaneous transcatheter closure under fluoroscopic guidance using the occluder device has been considered as a safe and effective alternative to open surgery with a higher technical success rate. However, and in selected cases it can be managed conservatively. In the current study we reported out local experience in the conservative non-surgical management of a patient presented with asymptomatic lately migrating and embolized amplatzer atrial septal defect occluder device into the supraceliac abdominal aorta. This conservative management was adopted after failure of the multiple trials of the endovascular retrieval of the embolized device. However, the procedure was terminated to keep away from any local vascular complications. The patient was followed up for more three years with serial computed tomography angiography on a scheduled outpatient basis. In the current study, we reported and sharing our local experiences for the non-operative, conservative management of a dislocated and embolized atrial septal defect occluder device to the supraceliac abdominal aorta.

Acute vascular complications of femoral venoarterial ECMO; a single center retrospective study

Funding Acknowledgements

Type of funding sources: None.

Backgroud

Emergent veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used to provide rapid cardiopulmonary resuscitation in adult patients with refractory cardiogenic shock . Femoral arterial cannulation may result in  ipsilateral limb ischemia due to  reduced distal  blood flow below the insertion point of the cannula .We retrospectively studied  adult patients supported with femoral VA-ECMO for cardiogenic shock between  2015 and 2019 at our tertiary care hospital. 

Results : the study included 65 adult patients supported on femoral VA-ECMO  for refractory cardiogenic shock . The studied patients had  a mean age of 37.9 ± 14.87 years , mostly males (70.8%) , a mean  BSA of 1.77 ±0.27 m2 and a mean BMI of 26.1 ± 6.7 kg/m2 . Twenty one (32.3%) patients developed acute lower limb ischemia. Femoral thrombectomy and angioplasty were done in 20 (30.8% ) patients . Four  (6.2%) patients developed limb compartmental syndrome and fasciotomy was done . Amputation of toes was done in one patient . The vascular complications included cannulation site bleeding in 24.6% of patients ,  femoral arteriovenous fistula in one patient and  large pseudoaneurysm after ECMO decannulation and required vascular surgical repair . Three (4.6%) patients developed chronic limb ischemia manifestations after hospital discharge . The patients who developed acute  limb ischemia had significantly frequent AKI (<0.001) without significant use of haemodialysis (p = 0.07) and longer ICU stay (p = 0.028) compared to the patients without limb ischemia. The hospital mortality occurred in 29 (44.6%)  patients  without significant difference between the patients with and without acute limb ischemia.  The  occurrence of acute  limb ischemia was significantly  correlated with failed percutaneous femoral cannulation (p = 0.039 )  while there was no significant statistical correlation between the  cut-down technique and occurrence of limb ischemia(p = 0.053).  The occurrence of femoral cannulation site bleeding was significantly correlated with failed percutaneous cannulation (p = 0.001 ) and cut-down technique (p = 0.001) . 

Conclusion :  Acute vascular complications are frequent after femoral VA-ECMO. Failed percutaneous femoral cannulation has been, in this study identified as the most important risk factor for acute limb ischemia and cannulation site bleeding. Recommendation: A careful approach during femoral cannulation is recommended to prevent occurrence of acute limb ischemia and femoral cannulation site bleeding. Abstract Figure. Cannulation approaches of VA-ECMO .

TEVAR Stent to the False Lumen of a Chronic Type B Aortic Dissection With Aneurysmal Dilatation, When no Other Options Are Left

We report a case of a 72 years-old male referred to us with a 2-year history of an enlarging aortic aneurysm secondary to a chronic Type B aortic dissection and a complete occlusion of the true lumen in the thoracic and abdominal aorta except at the level of visceral arteries origins. Several attempts to recanalize the true lumen was not successful. Because of the patient's high risk for an open repair and the normal size of his thoracic aorta proximal to the celiac artery, we deployed the TEVAR stent to the false lumen to prevent aneurysmal enlargement and rupture. The operation was successful, and the patient recovered without complications and with complete exclusion of the aneurysm on two years follow up.

Endovascular management of contralateral gate maldeployment during EVAR: Case report of interventional technique

INTRODUCTION

Endovascular repair of infra renal aortic aneurysm is becoming the preferable method of intervention compared to open surgery due to the lower early morbidity rates. One of the complications during the procedure is contra-lateral gate (CLG) maldeployment. Learning the endovascular salvage options is necessary to avoid the morbidities of open surgical conversion.

PRESENTATION OF CASE

we present a case of maldeployment during an endovascular exclusion of aortic aneurysm in a high cardiac risk patient for whom an endovascular management was successful.

DISCUSSION

We discuss the detailed technical aspect in managing CLG maldeployment in our case as well as variable options from literature.

CONCLUSION

Despite the available possibility to convert to open, there are multiple endovascular bail out alternatives to manage maldeployment that can be successfully performed by experienced interventionalist.

Free Esophageal Perforation Following Hybrid Visceral Debranching and Distal Endograft Extension to Repair a Ruptured Thoracoabdominal Aortic Aneurysm

Free esophageal perforation following a hybrid visceral debranching and distal endograft extension to repair a ruptured thoracoabdominal aortic aneurysm (TAAA) is a rare complication. The authors report a 56-year-old male who underwent elective thoracic endovascular aortic repair of a thoracic aneurysm. Four and a half years later, he presented with a new aneurysm extending from the distal end of the thoracic stent graft to the aortic bifurcation involving all the visceral arterial branches. The TAAA ruptured while he was awaiting an elective repair, and as a result, he underwent an emergency hybrid procedure. This involved debranching the visceral arterial branches including autotransplantation of the left kidney and distal endograft extension. Postoperatively, he developed free esophageal perforation secondary to ischemic necrosis requiring esophageal resection and gastric pull-up. The patient was well 6 months after the gastrointestinal restorative procedure. Thus, esophageal perforation following an emergency hybrid repair of ruptured TAAA is a rare complication, and a successful outcome depends on early recognition and surgical exclusion of the ruptured viscus.

Aortic valve disease in Marfan syndrome

The Marfan syndrome patient undergoes care by many different physicians for the treatment of the varied systems affected by this connective tissue disorder. The most frequent visits are to a cardiologist, with referral to a cardiovascular surgeon who attends to the problems of dilatation and dissection of the ascending aorta. Follow-up is lifelong. Although currently some surgeons prefer to resuspend rather than replace the aortic valve, composite valve graft replacement for aortic root dilatation and aortic valve insufficiency has steadily improved patient outcome. At the same time, the almost daily discoveries of genetic science show great promise in eliminating connective tissue disorders such as Marfan syndrome in the not-too-distant future.