Successful conservative management of iatrogenic femoral arterial trauma

We have developed a protocol for nonoperative management of pseudoaneurysms and arteriovenous fistulas secondary to cardiac catheterization. Hemodynamically stable patients were placed at bed rest and underwent serial physical examination, hematocrit, and duplex ultrasonography for a minimum of three days prior to discharge and subsequently as outpatients. Sixteen initially stable patients out of 56 with femoral artery catheter trauma managed over a four-year period underwent deliberate conservative management. Their lesions included six arteriovenous fistulas, seven pseudoaneurysms, and three patients with both complications. All but one of the pseudoaneurysms resolved spontaneously within four weeks regardless of initial size or associated arteriovenous fistula. One patient receiving anticoagulant therapy required surgery for bleeding after a three-day period of observation of a pseudoaneurysm. Six of the nine arteriovenous fistulas also resolved within the initial period of observation. The remaining three have been followed for four to 20 months and have remained asymptomatic. Nonoperative therapy of catheter-related femoral artery trauma is both safe and effective. Conservative management avoids potential wound complications associated with dissection through surrounding hematoma as well as the additional hospitalization required for postoperative care. We recommend a period of observation for all hemodynamically stable patients with catheter-induced pseudoaneurysms and arteriovenous fistulas of the femoral vessels, with surgery reserved for hemorrhage, expanding masses, or compromised cardiac output.Presented at the 16th Annual Meeting of the Peripheral Vascular Surgery Society, June 2, 1991, Boston, Massachusetts.     

Neurologic outcome after penetrating extracranial arterial trauma

PURPOSE: We undertook this study to determine factors that adversely affect outcome in patients with penetrating injury to the extracranial cerebral vasculature.Patients and methods Medical records were reviewed for all patients who had undergone surgical intervention to treat penetrating injury to the extracranial cerebral arteries between January 1989 and December 1999. Forensic autopsy findings were also reviewed for all patients who died as a result of their injury. RESULTS: One hundred fifty-one patients with injury to the brachiocephalic artery (n = 21), common carotid artery (n = 98), or internal carotid artery (n = 32) were identified. Overall mortality was 21.2%, and stroke rate in surviving patients was 15.1%. Twenty-five of 32 deaths (78.1%) were stroke-related. Brachiocephalic artery injury was associated with the highest mortality (38.1%), and survivor stroke rate was highest in patients with internal carotid injuries (22.7%). Hemodynamic instability at presentation led to both higher mortality (30.7%) and stroke rate (19.2%). Preoperative angiography did not influence mortality or stroke rate in hemodynamically stable patients. Procedural mortality associated with arterial ligation was 45% (9 of 20 patients), and no surviving patient experienced a change in pre-ligation neurologic state. Nine patients remained neurologically intact after ligation, and 2 patients with preoperative localized neurologic deficit were unchanged postoperatively. In 131 patients, mortality after arterial repair was 17.6%, and in 5 surviving patients (5.4%) an ischemic neurologic deficit developed. Twelve of 15 surviving patients (80%) with preoperative neurologic deficit who underwent arterial repair had improved neurologic status. Cerebral infarcts were confirmed at autopsy in 23 patients; 18 infarcts were ischemic (10, repair; 8, ligation), and 5 infarcts were hemorrhagic (all, repair). No factor was identified that was predictive of ischemic versus hemorrhagic infarction in patients undergoing repair. CONCLUSIONS: The presence of hypovolemic shock, internal carotid artery injury, complete vessel transection, and arterial ligation are associated with unfavorable outcome. Penetrating injury to the brachiocephalic, common carotid, or internal carotid artery should be repaired rather than ligated when technically possible. Subsequent ischemic or hemorrhagic cerebral infarction is unpredictable, but overall outcome is superior to that with ligation of the injured artery.     

Short bowel syndrome after trauma

PURPOSE: Traumatic injury to the intestine and its vasculature is a potential cause of short bowel syndrome (SBS). Our aim was to determine the incidence and mechanisms of traumatic injury to the bowel resulting in massive resection. METHODS: We reviewed the records of 196 adult patients evaluated with SBS over a 23-year period. RESULTS: Sixteen (8%) patients had SBS secondary to traumatic injury. Injury to the intestinal blood supply accounted for 81% (n = 13), and direct injury to the bowel wall accounted for the remaining 19% (n = 3). Nineteen associated injuries were present in 11 (67%) patients. CONCLUSION: Traumatic injury to the abdomen accounts for a small proportion of patients with SBS. These patients often have other associated injuries which might influence their outcome. Early diagnosis of vascular injury, use of second look procedures, appropriate resuscitation, and avoidance of all unnecessary resections may aid in prevention of this serious complication.     

Delayed fracture of the ceramic femoral head after trauma

There are various ways in which a total hip arthroplasty may fail catastrophically. Failure of the ceramic femoral head component is well known and described. It may fail because of trauma, but delayed fracture after trauma has not been described previously. This case report describes this phenomenon and postulates a possible mechanism for this failure.     

Collet-Sicard syndrome after minor head trauma

Occipital condyle fractures are rare and are usually associated with severe head and cervical spine injury. A 71-year-old man developed unilateral palsies of the 9th through 12th cranial nerves (Collet-Sicard syndrome) due to a fracture of the occipital condyle, which was diagnosed by computed tomography. He was treated conservatively and made a good recovery.     

Knotted femoral nerve catheter

We describe a case of knotting of a femoral nerve catheter which prevented removal by traction after knee replacement surgery. In this context, early surgical removal should be performed as bacterial colonization of femoral catheters is common. Radiological imaging of the catheter may assist decision-making about whether to persist with traction and what surgical approach is required. Minimizing the length of catheter inserted to less than 10 cm makes knotting unlikely, but will decrease the chance of achieving lumbar plexus blockade which could improve analgesia if the catheter passes centrally.     

Horner''s syndrome after intrapleural anesthesia with bupivacaine for post-herpetic neuralgia

We observed the development of Horner's syndrome 25 min after the intrapleural administration of 30 cc of 0.5% bupivacaine to a patient with post-herpetic neuralgia in the thoracic region. The patient reported immediate relief of pain. There was no change in blood pressure or pulse rate, and no discernible level of anesthesia to pinprick was detected.     

Brain placement of a double balloon catheter after extensive craniofacial trauma

An extensive craniofacial trauma is often associated with skull basal fractures and severe epistaxis. Such event requires nasal packing, using balloon systems or even arterial embolization or ligation. However, the use of balloon systems may result in an intracranial position. We report here such a case in an 18-year-old man suffering from a severe nasal bleeding.     

Floating nonocclusive thrombus in the common femoral artery detected by duplex scanning after removal of the arterial catheter: a case report

A 5-year-old girl is reported in whom duplex scanning showed a nonocclusive thrombus in the common femoral artery that was removed successfully by surgical intervention. Noninvasive examination with duplex scanning in patients with signs of acute arterial insufficiency during or after removal of femoral artery catheter is recommended.