股动脉穿刺介入治疗Angio-Seal血管闭合器应用并发症预测模型的构建与验证

目的 探讨股动脉穿刺后采用Angio-Seal血管闭合器发生并发症的危险因素并建立预测模型,为临床护理提供参考.方法 收集经股动脉入路行介入治疗、采用Angio-Seal血管闭合器的611例患者资料,行单因素和多因素Logistic回归分析并发症危险因素,建立风险预测模型进行验证.结果 体重指数、低分子肝素、鞘管尺寸、...     

The management of peripheral vascular complications associated with the use of percutaneous suture-mediated closure devices

PURPOSE: The purpose of this study is to identify the peripheral vascular complications associated with the use of percutaneous suture-mediated closure (PSMC) devices and compare them with postcatheterization femoral artery complications not associated with PSMC devices. METHODS: This is a retrospective review of all patients admitted to the vascular surgery service at the Chattanooga Unit of the University of Tennessee Department of Surgery with a peripheral vascular complication after percutaneous femoral arteriotomy between July 1, 1998, and December 1, 1999. The complications followed the use of PSMC devices (group I, n = 11) and traditional compression therapy (group II, n = 14) to achieve arterial hemostasis. Group II was subdivided into patients who required operative intervention (group IIA, n = 8), and those who were treated without operation (group IIB, n = 6). RESULTS: No significant difference was found between groups I and II with regard to age (P =.227), time to vascular surgery consultation (P =.987), or diagnostic versus therapeutic catheterization (P =.897). A significant difference was found with regard to mean pseudoaneurysm size (group I = 5.9 cm, group II 2.9 cm; P =.003). Ultrasound compression was successfully performed in 66.6% of group II patients, but no (0.0%) patient in group I responded to this therapy (P =.016). Groups I and IIA had a significant difference for mean estimated blood loss (group I = 377.2 mL, group II = 121.8 mL; P =.017) and requirement for transfusion (P =.013). More patients in group I required extensive surgical treatment (P =.007), with six of these patients requiring vein patch angioplasty during their treatment. More patients in group I also had infectious complications (n = 3) compared with group IIA (n = 1). CONCLUSION: In comparison with complications that follow percutaneous arteriotomy when PSMC devices are not used for hemostasis: (1) pseudoaneurysms after the use of PSMC devices are larger and do not respond to ultrasound compression, (2) complications associated with PSMC devices result in more blood loss and increased need for transfusion and are more likely to require extensive operative procedures, and (3) arterial infections after the use of PSMC devices are more common and require aggressive surgical management.     

Management of acute lower limb ischemia associated with the Angio-Seal arterial puncture closing device

Arterial percutaneous closure devices (APCD) could lead to severe vascular complications, like acute lower limb ischemia. The aim of this study was to evaluate retrospectively our personal series of acute lower limb ischemia following the use of APCD. From January 2004 to June 2009 the Angio-Seal percutaneous closure devices was deployed in 198 patients. Eight (4%) acute lower limb ischemia required urgent surgical repair. The device was removed in all cases. A thromboembolectomy was performed in five patients (62.5%) and in three (37.5%) an endarterectomy with patch closure was carried out (two saphenous vein and one Dacron). Limb salvage rate was 87.5%. We compared Angio-Seal complications group (A) with the 190 patients in which the Angio-Seal was successfully used without complications (group B) by means of Student's t-test. At 36-month follow-up with color-coded duplex ultrasounds, no chronic limb ischemia or other complications requiring surgical repair occurred. Diabetes, obesity, severe femoral atherosclerotic involvement, use of sheath size >7 Fr and time-consuming procedures were significant risk factors for ischemic APCD complications. Despite vascular injuries being uncommon after APCD deployment, generally a complex surgical repair is necessary. A more careful patient selection would be advisable.     

Surgical device closure a new technique of ASD closure

Background Conventional approach of atrial septal defect (ASD) closure with cardio pulmonary bypass using mid sternotomy, minimally invasive or endoscopic technique is time tested. We decided to use custom made device with direct minimally invasive approach without cardio pulmonary bypass. Percutaneous transfemoral route using custom made device is a well established procedure performed by interventional cardiologist with occasional trauma and vessels. Method We performed the procedure in 3 patients of secundum ASD deemed adequate for device closure. We used a mini Right anterior thoracotomy approach using a double umbrella device which was implanted through direct Right Atrial puncture. Results In two patients we were successful in deploying the device. The proedure lasted 30 minutes with small infra Mammary scar and the post operative period was uneventful. In the third case where our attempt at surgical device closure failed the inferior margin was only one mm. The optimal size device kept slipping into the right atrium when the guide-wire was tugged after final deployment. The placement of an oversize device distorted the mitral valve, may causing regurgitation. Conclusion We think that this is a simple and safe technique of secundum ASD closure without cardio pulmonary bypass.     

Surgical complications from hemostatic puncture closure devices

BACKGROUND: For securing immediate hemostasis following percutaneous arterial catheterization, the Food and Drug Administration has approved three hemostatic puncture closure devices. We reviewed our institutional experience with one device (Angio-Seal). METHODS: A retrospective, single-center, nonrandomized observational study was made of all vascular complications following femoral cardiac catheterization. RESULTS: An immediate mechanical failure of the device was experienced in 34 (8%) patients. Surgical repair was required in 1.6% (7 of 425) of patients following Angio-Seal versus 0.3% (5 of 1662) following routine manual compression (P = 0.004). In 5 patients, the device caused either complete occlusion or stenosis of the femoral artery. The polymer anchor embolized in 1 patient and was retrieved with a balloon catheter at surgery. CONCLUSION: During the first year of utilization of a percutaneous hemostatic closure device following cardiac catheterization, we observed a marked increase in arterial occlusive complications requiring surgical repair. Surgeons must be familiar with the design of these devices to achieve precise repair of surgical complications.     

Surgical complications associated with extensive tumoral calcinosis

In this article, we describe the presenting features, radiographic appearance, and proposed pathogenesis of tumoral calcinosis; highlight the surgical complications we have encountered with the syndrome; and review the complications reported in the literature.     

Complications associated with the Angio-Seal arterial puncture closing device: intra-arterial deployment and occlusion by dissected plaque

The Angio-Seal arterial closure device is widely used to prevent bleeding and facilitate early ambulation after arterial puncture. We had referred to us three female patients in whom this device had been used; its sponge had been unintentionally deployed in the arterial lumen. In a fourth female patient, a dissected plaque underneath the device occluded the femoral artery. Severe lower extremity ischemia occurred in each case. One intraluminal sponge was detected only after 20 days, when the patient had developed severe symptoms due to microembolization; in another patient, ischemia occurred 9 days after intraluminal deployment. In two, or possibly three, of the cases, the superficial femoral artery had been punctured. The device should not be used when the superficial femoral artery has been punctured, in which case complications are more likely to occur. Lower limb ischemia within several months after deployment of these devices should be investigated with duplex ultrasound scanning to examine the possibility that the ischemia may be caused by the device or by device-related thrombus. It is important to register the use of such devices in the procedural reports to make it possible to link their use to eventual later ischemic events.     

Complications associated with an implantable vascular access device

Purpose

Implantable vascular access devices (ports) are well accepted in the management of many pediatric conditions. Modifications have improved port function, patient satisfaction, and enhanced compatibility with imaging studies. We reviewed our experience with a port system and identified unique mechanical complications.

Methods

From 1998 to the present, 301 patients underwent 296 port insertions and 175 port removals. We assessed medical records, radiographs, and operative findings. The 6.6F MRI Low-Profile Implanted Port (Bard Access Systems, Salt Lake City, Utah) was used almost exclusively and was assembled by the operating surgeon. Outcome measures included port reservoir leakage, catheter dislodgment, and number of device days until complication. Ports were implanted for multiple medical problems including 74.2% in hematology/oncology patients.

Results

For 296 port insertions, 15 complications (5.1%) were identified in 13 patients (mean age, 8.4 years). Eleven leaks (3.7%) in 9 patients were found, with 9 leaks resulting from needle perforation of the port base and 2 leaks seen at the catheter connection site. Average port duration was 425 days (range, 12-1266 days) before leakage. Four patients had catheter dislodgment (1.4%), with 3 of 4 catheters embolizing to the heart or pulmonary artery. Patients were asymptomatic, and catheters were retrieved by interventional radiology. Dislodgment at the catheter-port connection site was seen in 3 of 4 cases, and average port duration was 1075 days (range, 269-2657 days) until catheter separation. Twelve of 13 patients had successful implantation of a new port system.

Conclusions

This study identifies that (1) mechanical port complications (5.1%) are not rare for this device; (2) regardless of port age, the thin plastic base may result in a risk of perforation not seen in other devices; (3) the extended period before embolization likely indicates device wear rather than faulty assembly; and (4) complications could be successfully managed including retrieval of embolized catheters.     

Surgical prophylaxis of gastroduodenal complications associated with renal allotransplantation

From 1971 to 1975, 226 patients received kidney allografts, and prophylactic ulcer surgery was regularly performed prior to kidney transplantation in those who had a history of previous ulcer, symptoms of peptic ulcer, a demonstrable ulcer on x-ray or endoscopy, gastric acid hypersecretion, or a temperament conducive to the development of peptic ulcer. The results of this prophylactic program were compared with those of the previous period from 1964 to 1970 when prophylactic ulcer surgery was not used in 77 kidney allograft recipients, and with those of the concurrent period obtained in 194 recipients who did not receive surgical prophylaxis. Initially, the prophylactic operation was truncal vagotomy with pyloroplasty, then it was proximal selective vagotomy (PSV) without pyloroplasty, and finally it was selective gastric vagotomy with pyloroplasty (SGV+P). The incidence of gastroduodenal complications in patients who did not receive prophylactic ulcer surgery was 22.1% during the period 1964–1970, and 15.9% during the period 1971–1975; the mortality rates from gastroduodenal complications were 10.4% and 4.6%, respectively. In contrast, only 1 of 32 renal transplant recipients who underwent prior prophylactic ulcer surgery developed a gastrointestinal complication, and there were no deaths in the prophylactic surgery group. Two patients developed fatal ischemic necrosis of the stomach following PSV, which led to the adoption of SGV+P as the prophylactic operation of choice.

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Résumé Entre 1971 et 1975, 226 malades ont eu une transplantation rénale. Tous ceux qui avaient des antécédents ou des symptomes d'ulcére gastroduodénal, un ulcère démontré par radiographie ou endoscopie, une hyperacidité gastrique, un tempérament ou un habitus prédisposant à l'ulcère ont subi, avant la transplantation rénale, une chirurgie prophylactique pour ulcère. Les résultats de ce programme préventif ont été comparés à ceux obtenus chez 194 malades qui, pendant la mÊme période, n'ont pas été soumis à une chirurgie gastrique, et aux résultats obtenus au cours de la période précédente (1964–1970), pendant laquelle cette chirurgie prophylactique n'avait pas été appliquée à 77 receveurs. L'opération utilisée a été, d'abord la vagotomie tronculaire avec pyloroplastie, puis la vagotomie sélective proximale sans pyloroplastie (PSV), enfin la vagotomie sélective gastrique avec pyloroplastie (SGV + P). Pour les malades sans chirurgie gastrique prophylactique, la fréquence des complications gastroduodénales a été de 22.1 % pour la période 1964–1970 et de 15.9 % pour la période 1971–1975, avec des mortalités de 10.4 et 4.6 %. Par contre, parmi les 32 malades soumis à une opération prophylactique, il n'y a eu qu'une seule complication gastroduodénale, et aucun décès. Deux malades ont présenté, après PSV, une nécrose ischémique mortelle de la paroi gastrique:c'est pour cette raison que nous avons adopté la SGV+P.

     

Toxic shock syndrome associated with the use of the vacuum-assisted closure device.

The vacuum-assisted wound closure technique and device (the V.A.C.) has become a widely accepted technique in the management of chronic and difficult wounds. The authors present the first reported case of toxic shock syndrome associated with its use. This article does not question the efficacy of the V.A.C. technique in the treatment of difficult wounds, but focuses on raising the index of suspicion of toxic shock syndrome in patients with wounds managed with the V.A.C. who develop early signs or symptoms that may be consistent with the diagnosis.     

Surgical treatment of colostomy complications

One hundred and twenty-three patients (M:F, 0.9:1; mean age 62 years) underwent 156 operations between 1954 and 1984 for correction of late colostomy complications (stenosis 65 patients, prolapse 16 patients, paracolostomy hernia 42 patients). Sixty-three per cent of patients eventually had a good result but in some up to 5 operations were necessary. Local excision of scar tissue at the mucocutaneous junction was associated with a 61 per cent (43/71) success rate for relief of colostomy stenosis. Where local fixation failed to prevent recurrent colostomy prolapse (13/20, 65 per cent of local fixation operations), colectomy and ileostomy was the most effective second procedure (2/3, 67 per cent success rate). Where local repair of a paracolostomy hernia failed (15/32, 47 per cent of local operations), resiting of the stoma to the umbilicus or right side of the abdomen produced better results (3/7, 43 per cent success rate) than resiting to another trephine on the left side of the abdomen (2/14, 14 per cent success rate).     

Avoidance of vascular complications associated with the use of dopamine.

Dopamine, dihydroxyphenylethylamine has three distinct actions depending on dosage. Low doses in the range of 1-2 mcg/kg/min result in vasodilatation. Medium doses of 2-10 mcg/kg/min increase cardiac output due to beta adrenergic action, while above 10 mcg/kg/min a potent vasoconstrictor effect predominates. Because of this last action great care must be used to avoid extravasation of infusions of dopamine directly into the tissue. Dopamine is a very useful agent but carries great potential to do local damage. Administration through a catheter placed into a large vein is recommended. Should extravasation occur, prompt infiltration of the area with phentolamine and a local anaesthetic, local cooling and regional sympathetic block may reduce the damage. The case is reported of a patient who suffered extensive necrosis in the forearm following local extravasation of dopamine.