Catheter‐Directed Thrombolysis of Acute Entire Limb Deep Vein Thrombosis From below the Knee Access

We report a case of early in‐stent restenosis due to collapse of a Magmaris resorbable magnesium scaffold.     

An unusual cause of chronic cough

Foreign body aspiration (FBA) is a serious medical problem, causing thousands of deaths nationally each year. Clinical presentations range from acute suffocation and death to chronic and subtle respiratory symptoms. Although FBA is more common in children, adult patients are also at risk. We present a classic case of FBA in an adult male with a history of alcohol abuse and chronic cough.     

Myocardial infarction due to intracoronary embolization of percutaneous coronary intervention packaging

Intracoronary device loss is occasionally encountered and removal is commonly performed at the time of the procedure. We report a case of removal of a retained coronary balloon protective plastic tubing inadvertently left in the coronary artery for a month and associated with myocardial infarction. Optical coherence tomography was used to visualize the foreign body prior to removal with a snare. To our knowledge this is the first report of a removal of disposable packaging equipment after prolonged intracoronary dwell time. © 2014 Wiley Periodicals, Inc.     

Paradoxical embolization of a fractured guidewire: successful retrieval from left atrium using a snare device.

In adults, paradoxical embolization of catheters or guidewire fragments related to central venous catheterization is a rare phenomenon. Reports of successful percutaneous retrieval of foreign bodies from the left atrium is also rare. We describe the successful percutaneous retrieval of a fractured guidewire that had undergone paradoxical embolization to the left atrium in an adult patient.     

Fighting fungus with a laser and a hose: Management of a giant Candida albicans implantable cardioverter‐defibrillator lead vegetation with simultaneous AngioVac aspiration and laser sheath lead extraction

Infections involving internal cardiac devices can be very challenging to treat, and almost universally require complete device extraction for successful management. Of the pathogens that cause device‐related endocarditis, fungi such as Candida albicans are notoriously difficult to manage because of their propensity to produce large vegetations and the need for long‐term treatment with potentially toxic medications. Furthermore, individuals who develop fungal, device‐associated endocarditis are typically among the most complex patients, with significant comorbidities that place them at high risk for open heart procedures such as surgical device extraction. We present a case of one such patient in whom treatment of Candida albicans device‐related endocarditis was managed using AngioVac^® aspiration of a large right atrial vegetation with simultaneous laser sheath extraction of the implantable cardioverter‐defibrillator lead.     

New endovascular technique for thrombus in the non‐stenting zone—the Grab a Clot and Hold ON “(GACHON) technique”: Case report

It is difficult to treat a thrombotic embolism in the common femoral artery or popliteal artery (POP A), i.e., the non‐stenting zone. We report a new technique for the treatment of thrombotic embolism in the non‐stenting zone using a self‐expandable nitinol stent. Case 1 had an external iliac artery (EIA) occlusion that occurred over several months. A self‐expandable nitinol stent was placed in the right EIA lesion via a retrograde approach using a distal 9‐Fr balloon protection guide catheter in the right femoral artery. A thrombotic embolism occurred at the balloon protection site. It was too big to be removed using an aspiration catheter; therefore, we attempted removal with a self‐expandable stent. Using a crossover approach, we delivered a nitinol self‐expandable stent to the distal site of the thrombus, opened the tip of the stent, and pulled it up to the proximal site. Finally, we “grabbed a clot,” moved it to the stenting zone, and “held on” the vessel wall without occurrence of a distal embolism. We named this the “GACHON technique.” Case 2 underwent endovascular therapy for an acute thrombotic embolism in POP A after thoracic endovascular aortic repair for dissection. This thrombus was too big to aspirate, and we successfully treated it using the “GACHON technique.” The “GACHON technique” may be considered as a choice of treatment for a thrombotic embolism in the non‐stenting zone. © 2016 Wiley Periodicals, Inc.     

The prevention of pregnancy‐related venous thromboembolism

Pregnancy‐related venous thromboembolism (VTE) remains one of the leading causes of maternal mortality and morbidity in the developed world. There is a lack of high‐level data surrounding the use of thromboprophylaxis in pregnancy. In the UK, following the publication of the first Royal College of Obstetricians and Gynaecologists (RCOG) guideline for VTE prophylaxis during pregnancy and the puerperium in 2004, a fall in maternal deaths secondary to VTE was observed during the subsequent triennium (2006–2008). For the first time since 1985, VTE was no longer the most common cause of maternal death. Low‐molecular‐weight‐heparin (LMWH) is generally the agent of choice for thromboprophylaxis in this setting, and is considered safe and efficacious. The accurate risk stratification of women in order to allow the targeted provision of thromboprophylaxis is challenging. A number of international guidelines support risk assessment for pregnancy‐related VTE and the provision of LMWH for those who are deemed at sufficiently high risk. This review describes the importance of VTE in pregnancy and the puerperium, the part played by different risk factors and the role of thromboprophylaxis in this group of patients.     

Chronic renal artery dissection with aneurysm formation treated by stent implantation with coil embolization with detailed intravascular ultrasound evaluation

Treatment options for chronic renal artery dissection, which is a rare cause of renal artery stenosis and renovascular hypertension, such as medical management, percutaneous intervention, and open surgical repair remain controversial. We describe a 55‐year‐old man with a chronic dissecting aneurysm of a renal artery complicated with renovascular hypertension that was initially diagnosed by computed tomography angiography, evaluated by intravascular ultrasound, and treated by stent implantation with coil embolization.© 2012 Wiley Periodicals, Inc.     

Preoperative coronary artery revascularization and long‐term outcomes following abdominal aortic vascular surgery in patients with abnormal myocardial perfusion scans: A subgroup analysis of the coronary artery revascularization prophylaxis trial

Background: Abdominal aortic operations have the highest perioperative cardiac risk. To test the impact of preoperative coronary artery revascularization (PR) in this high‐risk subset, a post hoc analysis was performed in patients undergoing aortic surgery within the Coronary Artery Revascularization Prophylaxis (CARP) trial. Methods: The study cohort was a subset of 109 CARP patients with myocardial ischemia on nuclear imaging randomized to a strategy of PR (N = 52) or no PR (N = 57) before their scheduled abdominal aortic vascular operation. The clinical indications for vascular surgery were an expanding aneurysm (N = 62) or severe claudication (N = 47). The composite end‐point of death and nonfatal myocardial infarction (MI) was determined by an intention‐to‐treat analysis following randomization. Results: The median time (Interquartiles) from randomization to vascular surgery was 56 (40, 81) days in patients assigned to PR and 19 (10, 43) days in patients assigned to no PR (P < 0.001). At 2.7 years following randomization, the probability of remaining free of death and nonfatal MI was 0.65 with PR and 0.55 with no PR [unadjusted P = 0.08, odds ratio = 1.67, 95% confidence interval (0.93, 2.99)]. Using a Cox proportional hazard model, predictors of the composite of death and nonfatal MI (odds ratio; 95% confidence interval) were no PR (1.90; 1.06–3.43; P = 0.03) and anterior ischemia on preoperative imaging (1.79; 0.99–3.23; P = 0.07). Conclusions: In patients with an abnormal cardiac imaging before abdominal aortic vascular surgery, PR was associated with a reduced risk of death and nonfatal MI while anterior ischemia was an identifier of poor outcome independent of the revascularization status. © 2010 Wiley‐Liss, Inc.     

Peripheral vascular interventional advances in 2017

Aim of this review is to inform major clinical trials in peripheral vascular interventions in the year of 2017.

     

Guidelines on travel‐related venous thrombosis

• ? Long duration travel is a weak risk factor for the development of venous thromboembolism (VTE). The incidence of VTE after flights of >4 h is 1 in 4656 and for flights of more than 8 h in low and intermediate risk flyers is around 0·5%.
• ? Severe symptomatic pulmonary embolism in the period immediately after travel is extremely rare after flights of <8 h. In flights over 12 h the rate is 5 per million.
• ? VTE may be attributable to travel if it occurs up to 8 weeks following the journey.
• ? The risk of travel‐related thrombosis is higher in individuals with pre‐existing risk factors for the development of VTE.
• ? There is no evidence for an association between dehydration and travel‐associated VTE and so whilst maintaining good hydration is unlikely to be harmful it cannot be strongly recommended for prevention of thrombosis (recommendation grade 2, level of evidence, B).
• ? There is indirect evidence that maintaining mobility may prevent VTE and, in view of the likely pathogenesis of travel‐related VTE, maintaining mobility is a reasonable precaution for all travellers on journeys over 3 h (2B).
• ? Global use of compression stockings and anticoagulants for long distance travel is not indicated (1C).
• ? Assessment of risk should be made on an individual basis but it is likely that recent major surgery (within 1 month), active malignancy, previous unprovoked VTE, previous travel‐related VTE with no associated temporary risk factor or presence of more than one risk factor identifies those travellers at highest thrombosis risk (1C).
• ? Travellers at the highest risk of travel‐related thrombosis undertaking journeys of >3 h should wear well fitted below knee compression hosiery (2B).
• ? Where pharmacological prophylaxis is considered appropriate, anticoagulants as opposed to anti‐platelet drugs are recommended based on the observation that, in other clinical scenarios, they provide more effective thromboprophylaxis. Usual contraindications to any form of thromboprophylaxis need to be borne in mind (2C).

     

Successful retrieval of an entrapped guide wire between a deployed coronary stent and severely calcified vessel wall using excimer laser coronary atherectomy

We report the successful retrieval of an entrapped interventional guide wire between a newly deployed coronary stent and severely calcified vessel wall. Using a buddy wire technique, the stent was deployed at high pressure in a culprit lesion of the left anterior descending (LAD) artery. The buddy wire in the LAD artery was entrapped between the deployed stent and severely calcified vessel wall, as it was not removed before stent deployment, and could not be retrieved. Neither balloon catheters nor a microcatheter were able to be advanced behind the stent over the entrapped guide wire. Excimer laser coronary atherectomy (ELCA) was performed within the stent to modify and soften the calcification behind the deployed stent. Consequently, the entrapped guide wire was retrieved successfully and safely. This case illustrates that ELCA can be utilized to retrieve an entrapped guide wire between a deployed stent and calcified vessel wall. © 2014 Wiley Periodicals, Inc.     

The use of pigtail catheters for retrieval of foreign bodies from the cardiovascular system

Snare retrieval of foreign bodies is a common procedure but in certain cases, location of the foreign body requires another system. We present three cases in which only the use of a pigtail catheter gave a good grip for gentle traction and removal or repositioning of the foreign body. A careful review of the world literature up to December 1982 gave rise to two previous similar reports. Both our experience and that found in the literature seem to suggest that in cases where there are no free ends to snare, pigtail catheters may be the first instrument used to start retrieval.