RESUMEN
PURPOSE: To report the percutaneous endovascular repair of massive congenital arteriovenous malformations (AVMs) of the right arm complicated by tissue ischemia, severe edema, and life-threatening recurrent hemorrhagic episodes. METHODS AND RESULTS: A 25-year-old man with a 3-year history of symptomatic upper right arm AVMs had been treated unsuccessfully with surgical ligation and coil embolization. The arm had become massively enlarged, disfigured, severely painful, and unusable, with extension of swelling to the upper chest. Under compassionate use as part of an investigational protocol, the AVMs were closed with 6 overlapping Wallgraft endoluminal prostheses deployed in the right brachial, axillary, and subclavian arteries, preserving the vertebral and distal circulations. Unfortunately, the patient suffered numerous pulmonary emboli and died 2 days after the procedure. CONCLUSIONS: Percutaneous treatment of massive AVMs appears feasible with the Wallgraft endoprosthesis, but optimal postprocedural management of such large anomalies should include immediate venous filter placement and aggressive anticoagulation therapy with intravenous heparin.
Asunto(s)
Brazo/irrigación sanguínea , Malformaciones Arteriovenosas/terapia , Stents , Adulto , Angiografía , Malformaciones Arteriovenosas/diagnóstico por imagen , Humanos , MasculinoRESUMEN
Three patients from different centers with pacemaker or ICD leads endocardially implanted in the left ventricle are described. All leads, two ventricular pacing leads and one ICD lead, were inserted through a patent foramen ovale or an atrial septum defect. The diagnosis was made 9 months, 14 months, and 16 years, respectively, after implantation. All patients had right bundle branch block configuration during ventricular pacing. Chest X ray was suggestive of a left-sided positioned lead except in the ICD patient. Diagnosis was confirmed with echocardiography in all patients. One patient with a ventricular pacing lead presented with a transient ischemic attack at 1-month postimplantation. During surgical repair of the atrial septum defect 14 months later, the lead was extracted and thrombus was attached to the lead despite therapy with aspirin. The other patients were asymptomatic without anticoagulation (9 months and 16 years after implant). No thrombus was present on the ICD lead at the time of the cardiac transplantation in one patient. We reviewed 27 patients with permanent leads described in the literature. Ten patients experienced thromboembolic complications, including three of ten patients on antiplatelet therapy. The lead was removed in six patients, anticoagulation with warfarin was effective for secondary prevention in the four remaining patients. In the asymptomatic patients, the lead was removed in five patients. In the remaining patients, 1 patient was on warfarin, 2 were on antiplatelet therapy, and in 3 patients the medication was unknown. After malposition was diagnosed, three additional patients were treated with warfarin. In conclusion, if timely removal of a malpositioned lead in the left ventricle is not preformed, lifelong anticoagulation with warfarin can be recommended as the first choice therapy and lead extraction reserved in case of failure or during concomitant surgery.
Asunto(s)
Bloqueo de Rama/etiología , Desfibriladores Implantables , Análisis de Falla de Equipo , Defectos del Tabique Interatrial/complicaciones , Ventrículos Cardíacos , Marcapaso Artificial , Tromboembolia/etiología , Adolescente , Anciano , Anticoagulantes/administración & dosificación , Bloqueo de Rama/diagnóstico por imagen , Bloqueo de Rama/terapia , Remoción de Dispositivos , Ecocardiografía , Electrocardiografía , Electrodos Implantados , Femenino , Defectos del Tabique Interatrial/diagnóstico por imagen , Ventrículos Cardíacos/diagnóstico por imagen , Humanos , Cuidados a Largo Plazo , Masculino , Factores de Riesgo , Tromboembolia/diagnóstico por imagen , Tromboembolia/terapia , Warfarina/administración & dosificaciónRESUMEN
PURPOSE: To report early experience using a vascular closure device following endovascular aortic aneurysmal repair in which large-bore sheaths are used. TECHNIQUE: A 10F Prostar XL Percutaneous Vascular Surgery device is used to deploy sutures around sheath entry sites up to 16F. At the completion of the procedure, the sutures are tied with a sliding knot to ensure adequate hemostasis. CONCLUSIONS: Maintaining the minimal invasiveness of the percutaneous approach to aortic endografting reduces patient discomfort and permits earlier ambulation and hospital discharge. Initial success seems to be maintained at 1 month, however, longer follow-up will be required.