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Acute Limb Ischaemia
Published in James Michael Forsyth, How to Be a Safe Consultant Vascular Surgeon from Day One, 2023
The patient goes to interventional radiology for thrombolysis. He has a sheath inserted into the contralateral groin (i.e. retrograde access, up and over approach to left leg) and then is brought back to HDU. You see the patient the following day on the vascular ward round. The nurses are concerned because there is some minor oozing around the right femoral sheath. They are also asking you about the heparin dose and are asking you how often you want the fibrinogen level checked?“I would be happy to continue thrombolysis if this was only very minor bleeding, as the benefits seem to outweigh the risks. In terms of checking fibrinogen levels and continuing, the up-to-date ESVS guidelines on acute limb ischaemia do not recommend routine monitoring of plasma fibrinogen, nor continuous systemic therapeutic heparinisation. This is because there is no strong evidence that low fibrinogen levels have a strong predictive value for bleeding during thrombolysis, and that continuous heparin administration is associated with an increased bleeding risk.”
Complications of percutaneous intervention for femoral, popliteal, and infrapopliteal artery occlusive disease
Published in Sachinder Singh Hans, Mark F. Conrad, Vascular and Endovascular Complications, 2021
Renganaden Sooppan, Christopher J. Abularrage
Arteriovenous fistula (AVF) occurs when there is a direct connection between an artery and a vein. It is usually an iatrogenic complication of EVT when the artery and the vein are in close proximity and there is through-and-through access across the abutting walls of both structures. If a sheath is exchanged after micropuncture access, a larger common channel is formed, which allows for continuous flow from the artery into the vein. Multiple blind attempts with lateral and medial deviation of the needle from the CFA in the femoral sheath can lead to a combined venous and arterial puncture.10 Another instance occurs when the CFA is accessed close to its bifurcation, and the proximal deep femoral artery or superficial femoral artery together with the lateral femoral circumflex vein can be accidentally punctured together resulting in an AVF.
Complex lower extremity revascularization
Published in Peter A. Schneider, Endovascular Skills: Guidewire and Catheter Skills for Endovascular Surgery, 2019
The most important features of success in tibial interventions is strategy followed by attention to detail. The patient must be fully anticoagulated. Inflow lesions must be treated aggressively. The sheath must be placed as close as can safely be achieved to the location where the infrapopliteal intervention will be performed. If ipsilateral antegrade femoral sheath access can be achieved, that is usually best. Almost always, there are multiple vessels involved, and picking the best targets can be a challenge. One might consider going after the simplest tibial lesion that will bring more flow to the foot. Secondarily, if there is another vessel involved that can bring more blood supply to the wound-related artery, which would be correct from an angiosome point of view, then typically that one is also opened.
Retrograde trans-posterior communicating artery rescue balloon angioplasty of incompletely expanded pipeline embolization device: complication management
Published in British Journal of Neurosurgery, 2023
Amey R. Savardekar, Devi Prasad Patra, Anil Nanda, Hugo Humberto Cuellar-Saenz
The patient complained of severe neck pain during these attempts and was placed under general anaesthesia. We exchanged the right femoral sheath for a shuttle sheath placed at the right internal carotid artery (ICA). A 5 Fr Navien catheter (Medtronic, Irvine, CA, USA) was advanced into the right cavernous ICA, an Excelsior SL-10 micro-catheter was advanced over a 0.014 Synchro glide-wire through the right posterior communicating artery, into the right P1 segment and down the basilar artery to access the stent at the left V4 segment in a retrograde fashion. With the micro-catheter past the stent in the left VA, we advanced a 0.014 exchange wire. The micro-catheter was removed and a 3 × 10 mm Transform balloon (Stryker Neurovascular, Fremont, CA, USA) was advanced and placed across the stent. Once the balloon was inside the PED in the left VA, we performed successive rounds of angioplasty widening the narrowed segment of the PED (Figure 3(A,B)). At this moment, the left femoral artery was accessed with a 5 French sheath (Terumo, Somerset, NJ, USA) and a JB-1 catheter was advanced to catheterize the left VA. DSA runs after angioplasty showed complete patency of the left VA and complete occlusion of the aneurysm with no flow restriction to basilar artery (Figure 3(C,D)).
Impact of routine use of a cerebral protection device on the TAVR procedure and its short-term outcomes: a single-centre experience
Published in Acta Cardiologica, 2022
Marnix J. von Kemp, Vincent Floré, Chirik Wah Lau, Johan De Sutter, Frank Provenier, Kristoff Cornelis
Sentinel CPS can be used in minimally invasive TAVR without significant lengthening of the procedure duration, increased X-ray use or increase in complications. It does not halt the continuous evolution towards less invasive TAVR. At the start of our TAVR programme in 2010, TAVR was performed in the operating room, with cardiac surgery on stand-by, under general anaesthesia, with transoesophageal echocardiographic guidance, bilateral femoral access with crossover injection, surgical arterial cut-down for the large bore access, venous access for temporary pacing, jugular deep venous catheter, and a bladder catheter. TAVR gradually evolved to a far less invasive procedure, and can be performed under local anaesthesia with anaesthesiologist support present (monitored anaesthesia care). Access can nowadays be limited to a single arterial femoral sheath placed under echographic guidance (with pacing over the left ventricular guidewire) and a peripheral venous catheter only. This shortens the procedure and the postprocedural recovery time, and almost completely eliminates the need for postprocedural intensive care. In uncomplicated procedures, this allows patients to return home within 48 h after the procedure. In our study population, mean hospital stay duration was 5-6 days, mostly due to historical habits and social reasons in an elderly population. This is expected to shorten in the near future. Avoiding cerebral embolisation with dedicated devices will only play a positive supplemental role here.
De Garengeot hernias. Over a century of experience. A systematic review of the literature and presentation of two cases
Published in Acta Chirurgica Belgica, 2022
Michail Chatzikonstantinou, Mohamed Toeima, Tao Ding, Almas Qazi, Niall Aston
The femoral canal is the most medial compartment of the femoral sheath, which is bordered anterosuperiorly by the inguinal ligament, medially by the lacunar ligament, laterally by the femoral vein and posteriorly by the pectineal ligament. It contains fat lymphatics and the lymph node of Cloquet. A large mobile caecum that extends into the pelvis is the usual reason for the appendix to enter the hernia sac into the femoral ring [13–15]. The abnormal low position of the bowel creates a mass effect that pushes the appendix into the femoral canal, while an abnormal embryological rotation of the gut increases the probability of appendiceal herniation. Intraoperative findings of normal non-inflamed appendix favour the theory of herniation of the appendix and subsequent inflammation rather than incarceration of an already inflamed appendix. The tight rigid femoral ring acts as an entrance to an anatomically confined space for strangulation, inflammation and, eventually, vascular congestion, necrosis and perforation of the appendix.