Evidence Of Hematoma Research Articles

Action protocol of medical staff for airway obstruction after anterior cervical spine surgery: A systematic review of case reports

BackgroundPostoperative airway obstruction after anterior cervical spine surgery (ACSS) can be a fatal complication. Occasionally, it rapidly progresses to complete obstruction. There are no established standardized protocols on how medical staff should assess for signs and symptoms, seek help, or facilitate airway management after ACSS to prevent unfavorable events. This study aimed to primarily describe a systematic approach by assessing the signs and treatment outcomes of airway compromise in patients who underwent ACSS. Further, it recommended an action protocol after extubation for medical staff according to patients’ symptoms to prevent unfavorable outcomes. MethodsAn extensive literature search was performed on PubMed, Web of Science, and the Cochrane Library to identify case reports, case series, and cohort studies restricted to English and published between January 1990 and March 2023. We included cases that described the signs, symptoms, and treatment of airway obstruction after ACSS. Meanwhile, cases involving complications of other known causes, cases of trauma or occipital-cervical fixation, or those using bone morphogenetic protein were excluded. ResultsTwenty cases from 17 studies were obtained, and their study quality was acceptable. Four patients died, and two presented with hypoxic ischemic encephalopathy. Further, five of six patients had fatal complications that initially developed within 7 h after surgery. Then, 9 (69%) of 13 patients with evidence of hematoma (69%) showed initial symptoms within 12 h after surgery. Finally, 9 of 11 patients with early-stage symptoms had favorable outcomes, and patients who developed late-stage symptoms commonly had unfavorable outcomes. ConclusionThe early identification of signs and symptoms and immediate treatment are important, particularly within 12 h postoperatively. We suggest a novel action protocol for medical staff according to symptom urgency, which includes the measurement of neck circumference using a string for evaluating neck swelling.

Percutaneous coronary intervention for chronic total occlusion of the left circumflex branch in mirror dextrocardia: a case report

BackgroundMirror dextrocardia (MDC) is a condition in which the heart is located in a mirror-image position on the right side of the chest compared to the normal position in individuals with physiological variations. Patients with MDC and chronic total occlusion (CTO) of the left circumflex branch (LCX) are extremely rare in clinical practice. The treatment of MDC-CTO-LCX differs significantly from patients without mirror dextrocardia and the same condition in terms of instrument selection and procedural techniques. In this article, we report a successful case of interventional treatment in a patient with MDC-CTO-LCX. We summarize the anatomical and electrocardiographic variations in patients with MDC-CTO-LCX, and discuss the selection of interventional instruments and techniques that can be useful for interventionists as well as the diagnostic and therapeutic considerations that can be helpful for clinical physicians.Case presentationA male Han Chinese patient, 51, was admitted, presenting recurrent chest pain for a year and recent onset of exertional fatigue over the past week.He reported episodes of chest pain following physical activities over the past year, lasting between 5 and 20 min.Despite these symptoms, the patient did not seek immediate medical attention, and the occurrence of his chest pain has progressively lessened within the year.A week prior, the patient developed exertional dyspnea after brief walks, though without any episodes of nocturnal paroxysmal dyspnea.Upon arrival at our hospital for evaluation, he was initially diagnosed with chronic coronary syndrome, previous inferior myocardial infarction, atrial arrhythmia, and classified under the New York Heart Association functional class III.Following his admission, a chest X-ray and coronary angiography were conducted.The results indicated mirror dextrocardia and total occlusion of the left circumflex branch. Percutaneous coronary intervention (PCI) was performed on the left circumflex branch. Subsequent angiography demonstrated optimal stent positioning without evidence of hematoma or dissection.Following the procedure, the patient's symptoms of chest pain and exertional dyspnea were resolved, which led to his subsequent discharge.A follow-up electrocardiogram, 10 months post-procedure, displayed a slow and regular atrial rhythm.ConclusionsThe incidence of dextrocardia is very low, and it may appear normal on an electrocardiogram; however, careful diagnosis is required when there is an abnormal direction of the P wave in limb leads. During the operation for chronic occlusive lesions of the right-sided coronary artery, the anomalous anatomical structure necessitates specific requirements for instrument selection and operative techniques. After revascularization of chronic occlusive vessels in dextrocardia, routine electrocardiographic examination may show false normalization, requiring caution in interpretation.

Evaluation of esophageal injuries after defibrillation with transesophageal ultrasound probe in the mid-esophagus in pigs

ObjectiveTransesophageal echocardiography (TEE) is becoming increasingly utilized by emergency medicine providers during cardiac arrest. Intra-arrest, TEE confers several benefits including shorter pauses in chest compressions and direct visualization of cardiac compressions. Many ultrasound probe manufacturers recommend against performing defibrillation with the TEE probe in the mid-esophagus for fear of causing esophageal injury or damage to the probe, however no literature exists that has investigated this concern. To assess this, we performed cardiopulmonary resuscitation (CPR) and multiple defibrillations in 8 swine with a TEE probe in place. MethodsWe performed TEE on 8 adult swine during CPR and performed multiple 200 J defibrillations with the TEE probe in the mid-esophagus. Post-mortem, esophagi were dissected and inspected for evidence of injury. ResultsOn macroscopic inspection of 8 esophagi, no evidence of hematoma, thermal injury, or perforation was noted. ConclusionOur study suggests that performing defibrillation during CPR with a TEE probe in place in the mid-esophagus is likely safe and low risk for significant esophageal injury. This further bolsters the use of TEE in CPR and would enable continuous visualization of cardiac activity without the need to remove the TEE probe for defibrillation.

AB0783 “RICE AND SARDINES”: AN UNUSUAL CAUSE OF RASH AND JOINT SWELLING

Background:Systemic vasculitis presents with numerous widespread manifestations. Various diseases can masquerade as systemic vasculitis (1). It is crucial to carefully evaluate patients with unusual presentations to look for vasculitis mimics. Scurvy, a disease caused by severe and prolonged vitamin C deficiency, still occurs in industrialized countries (2). Ascorbic acid is involved in various biologic processes including the synthesis of mature collagen. Lack of ascorbic acid especially affects blood vessel integrity leading to haemorrhagic manifestations characteristic of scurvy (3).Objectives:Case report highlighting that scurvy is still prevalent in the west and may present with features resembling vasculitis.Methods:Information was obtained from the patient’s medical records.Results:A 61 year old Caucasian female presented with a 3 weeks’ history of bilateral lower limb pain, rash and swelling. She was referred to acute medicine to exclude deep vein thrombosis suspected by her general practitioner. She was previously fit and well apart from diagnosis of coeliac disease and various food intolerances. She believed her symptoms started following a recent course of Metronidazole for suspected dental infection which manifested with gum bleeding.She was found to have purpuric spots and ecchymosis bilaterally in her legs, from the toes to the groin. The left knee was swollen with evidence of hematoma around the joint.She denied fever, weight loss, night sweats, arthralgia, myalgia, rash, Raynaud’s, alopecia, mouth or genital ulcers, ear-nose-throat manifestations. She denied chest pain, difficulty in breathing or symptoms of peripheral neuropathy. There was no history of asthma, inflammatory bowel disease or uveitis. She reported occasional alcohol intake, she did not smoke cigarettes nor use recreational drugs. Examination otherwise revealed no other major abnormalities with normal vital signs.Initial differential diagnosis included platelet or coagulation disorders or vasculitis. Initial blood tests revealed normal full blood count, coagulation screen, ESR, CRP, liver and renal biochemistry.Urine dip was positive for blood but not for protein. Knee aspiration was attempted but no fluid could be aspirated. Knee x-ray was unremarkable. ANA, ANCA and anti-GBM antibody tests were negative.On further review and enquiry into her symptoms and lifestyle she admitted having a diet exclusively of “rice and sardines” for nearly 2 years. This information along with clinical features led to the suspicion of Vitamin C deficiency that was subsequently confirmed. Ascorbic acid levels were <2.8micromol/l (normal range 26.1-84.6.micromol/l).Replenishment of vitamin C was followed by a rapid and sustained recovery. Detailed investigation for additional macro and micronutrient deficiencies were undertaken with referral to a dietician and to gastroenterology.Conclusion:This case illustrates scurvy can present in previously “well” individuals and should be considered as a possible differential diagnosis of vasculitic lesions in the appropriate clinical context. Detailed dietary history is invaluable.

460 Placental-abruption with and without sonographic evidence of placental hematoma – pregnancy outcomes and placental pathology

Placental abruption is traditionally diagnosed based on clinical symptoms. The role of ultrasound in the diagnosis (through evidence of hematomas) remains questionable. Therefore, we aimed to compare pregnancy outcomes and placental histopathology in cases of placental abruption (PA) with and without sonographic evidence of placental hematoma. Pregnancy and placental reports of all pregnancies complicated by PA (diagnosed clinically) between 11/2008-7/2019 in a single tertiary center were reviewed. All ultrasound scans of each patient throughout the pregnancy were reviewed for sonographic evidence of placental hematoma (of any size, location, and timepoint during pregnancy). Maternal background characteristics, pregnancy outcomes, and placental histopathology lesions were compared between cases of PA with and without sonographic evidence of a placental hematoma. Placental lesions were classified according to the current "Amsterdam" criteria. A total of 307 PA cases were included. Of them, 270 (87.9%) in the PA without a placental hematoma group and 37 (12.1%) in the PA with placental hematoma group. Maternal demographics including maternal age, hypertensive diseases, diabetes, and smoking did not differ between the groups. The PA with placental hematoma group was characterized by an earlier gestational age at delivery (32.8 ± 4.8 vs 36.8 ± 4 weeks, p< 0.001), and higher rates of NICU admissions (p=0.034), respiratory distress syndrome (p=0.007), phototherapy (0.014), and neonatal sepsis (p=0.040). Placentas from the PA with placental hematoma group were characterized by lower fetoplacental ratio (p<0.001) and higher rates of histologic chorioamnionitis (p<0.001) and chronic villitis (p<0.001). The presence of a sonographic placental hematoma in cases of PA was associated with a significantly lower gestational age at delivery and a higher rate of adverse neonatal outcomes. This association may be attributed to differences in placentation and inflammation as both acute and chronic inflammatory placental lesions were higher in this subgroup of PA.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Mortality and serious injury of northern right whales (Eubalaena glacialis) in the western North Atlantic Ocean

Northern right whales in the western North Atlantic number about 300 animals and have shown little sign of recovery in recent decades.Mortality and serious injury due to human activities, particularly commercial fishing and shipping, are thought to be significant factorslimiting their recovery. From 1970-1999, 45 right whale deaths were reliably documented. Sixteen of these fatalities (35.5%) were due toship collisions, and three (6.7%) were due to entanglement in fishing gear. The remainder were neonates (13; 28.9%) and ‘unknown cause’mortalities (13; 28.9%). Criteria for defining serious injuries and mortalities from entanglement or ship strikes were developed and includeany animal carrying fishing gear, cuts from entanglement or ship strike deeper than 8cm, swelling or necrosis, evidence of poor health fromsuch interactions, and, in carcasses, evidence of haematoma, haemorrhaging or broken bones. A total of 56 animals fitting the definedcriteria were documented from 1970-1999: 31 (55.4%) from entanglement and 25 (44.6%) from ship strikes. Nineteen were fatal (16 shipstrikes, 3 entanglements), 10 were possibly fatal (2 ship strikes, 8 entanglements) and 27 were non-fatal (7 ship strikes, 20 entanglements).The breakdown of potentially serious injuries by age and sex reveals no difference in levels between sexes but shows a 3.3:1 higher levelof interaction in juveniles and calves versus adults. The data show that ship strikes are more immediately lethal, but entanglements can resultin long term deterioration of an animal and may be responsible for higher levels of mortality than previously thought. Considering that someanimals become entangled, drown and never return to the surface, even these levels may be underestimated. Between 1986 and 1999, 84animals were presumed dead based on a lack of resightings for six years. There were 32 confirmed deaths during this time period suggestingthat at least as many unreported deaths occurred as carcasses were reported. Definitive actions need to be taken to reduce the level andseverity of anthropogenic injuries and deaths. Actions could include continued disentanglement efforts, gear modifications, seasonalclosures for fisheries, mandatory ship reporting, ships’ routing measures and speed restrictions for commercial shipping.

Long-term Outcomes Following Endovascular Aneurysm Repair for Ruptured Abdominal Aortic Aneurysms

Purpose: To investigate the long-term outcomes of endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysm (rAAA) from a single center over an 11-year period. Materials and Methods: A retrospective analysis was conducted of 121 patients (median age 78 years; 100 men) with rAAA who underwent emergency EVAR at a single tertiary vascular center from January 2006 to December 2016. The study included only ruptures confirmed by evidence of hematoma on preoperative computed tomography; both iliac and aortic aneurysm ruptures were eligible. The primary outcome measures included mortality and reintervention rates. Kaplan-Meier estimates of survival and freedom from reintervention are reported with the 95% confidence interval (CI). Results: In-hospital and 30-day mortality rates for emergency EVAR were 16.5%; 90-day mortality was 24.0%. The mortality estimates were 27.3% (95% CI 20% to 36%) at 1 year and 61.7% (95% CI 51% to 72%) at 5 years. In the observation period to 2017, 63 reinterventions were performed on 37 patients (30.6%). Median time to the first reintervention was 3.2 years. Freedom from reintervention in surviving patients at 1 year was 86% (95% CI 72% to 94%) and 51% (95% CI 26% to 71%) at 5 years. Four patients (3.3%) had a secondary sac rupture over the study period. Conclusion: Emergency EVAR for ruptured AAA can be performed with acceptable short-term outcomes; however, long-term surveillance is necessary, and reintervention is common.

PRO105 COMPLICATIONS ASSOCIATED WITH CENTRAL VENOUS ACCESS DEVICES IN PATIENTS WITH HEMOPHILIA A (PWHA): A SECONDARY CLAIMS-BASED ANALYSIS

To evaluate incidence of complications associated with central venous access devices (CVADs) in PwHA. This retrospective cohort study was conducted using claims data from MarketScan Commercial Research Database from 07.01.2005–03.31.2019. The study cohort comprised PwHA and included CVAD cases (≥1 CVAD insertion claim), and controls with no CVAD insertion claim through the study period. Patients were required to have continuous enrollment for 6 months pre- and at least 3 months post-index date. Index date was defined as the first date of port insertion for CVAD cases and first hemophilia A (HA) diagnosis for controls during the study period. HA was identified using a previously validated claims-based algorithm. CVAD use and complications (all-cause infections, thrombosis and hematoma) were identified using ICD-9-CM/ICD-10-CM diagnosis/procedure and CPT codes. Patients were followed until first outcome, plan switch or over a 2-year post-index period. Incidence and rates of complications among CVAD cases and controls were evaluated using Cox proportional-hazards models (adjusted for age, region, comorbidity score, and insurance type). The study cohort comprised 862 PwHA; 61 (7%) had evidence of CVAD use. CVAD cases were significantly younger than controls (mean age ± SD: 4.7±5.3 years vs. 25.9±17.5 years, p<0.001) and had a significantly higher Elixhauser comorbidity score (mean ± SD: 0.9±0.6 vs. 0.5±0.8, p<0.001). In the post-index period, a significantly higher proportion of CVAD cases (vs. controls) had all-cause infections (44.3% vs. 26.7%, p<0.001) and thrombosis (13.1% vs. 1.1%, p<0.001). No CVAD cases had evidence of hematoma; it occurred in 1.5% of controls. Cox models revealed that CVAD cases had 2.3 times (95%CI: 1.5–3.6) and 9.2 times (95%CI: 2.4–35.6) higher rate of all-cause infections and thrombosis, respectively. CVAD use in HA is associated with higher rates of complications, underscoring the need for novel non-intravenous treatments which remove the need for CVADs.

Patient Survival after a Very Deep Penetrating Orbitocranial Injury.

Patient Survival after a Very Deep Penetrating Orbitocranial Injury.

Vascular closure devices after endovascular procedures in swine: a reliable method?

Purpose. To investigate the safety and feasibility of the use of a vascular closure device (VCD) after endovascular procedures in swine. Material and Methods. In a study on endovascular therapy, VCD (StarClose, Abbott Vascular, Il, USA) was used in 20 female swines to achieve immediate hemostasis after percutaneous right femoral artery (FA) access. 10 animals were sacrificed immediately after the study and 10 animals were sacrificed 28 days after the initial study. To ensure complete hemostasis and patency of the femoral artery, a CT-angiography of the puncture site was performed on day 1 (acute and chronic group) and day 28 (chronic group). After the sacrifice, the femoral artery was explanted and examined macroscopically for signs of VCD dysfunction. Results. Technical success rate was 100% with immediate hemostasis being achieved in all animals. No animals showed evidence of hematoma. During explantation, only small traces of coagulated blood were found in the acute group, while there were no signs of hematoma in the chronic group. CT-angiography immediately after VCD application as well as before sacrifice (chronic group) showed patency of the FA in all cases. Conclusion. The use of VCD to achieve hemostasis after endovascular studies in swine is feasible and safe.

Femoral Venous Hemostasis in Children Using the Technique of “Figure-of-Eight” Sutures

Structural heart interventions require the use of relatively large-diameter delivery sheaths or latex nylon net balloon catheters, which results in a relatively large-diameter venous puncture point. At present, femoral venous hemostasis is achieved by manual compression. A temporary figure-of-eight subcutaneous suture has been introduced to achieve immediate postprocedural femoral venous hemostasis after using a ≥24Fr sheath in an adult. This method is not well evaluated in children. We report our experience using this technique in children treated with 7-14Fr sheaths. From May 2009 to March 2012, 104 children (ages ranging from 3 to 10 years, mean 8.1 ± 1.6 years) with atrial septal defects (n = 86) and pulmonary valve stenosis (n = 18) underwent percutaneous transcatheter interventions. Sheath sizes used were ≥7Fr (7Fr, n = 5; 8Fr, n = 29; 9Fr, n = 14; 10Fr, n = 15; 12Fr, n = 19; 14Fr, n = 22). A total of 102 patients had immediate femoral vein hemostasis, and 2 developed a femoral vein hematoma requiring manual compression. One patient was diagnosed with a femoral artery pseudoaneurysm during hospitalization. On follow-up, there was no evidence of hematoma or thrombosis. The "figure-of-eight" suture technique is effective and safe, achieving immediate hemostasis after the use of large femoral vein sheaths in children.

Recurrent psychogenic paresis after dural puncture in a parturient

We describe the case of a 29-year-old parturient who, after undergoing elective cesarean delivery, displayed symptoms of lower extremity weakness and sensory deficit. Her past medical history was significant for asymptomatic Arnold Chiari Type I malformation and asthma. She had received spinal anesthesia that failed to achieve an adequate surgical level requiring conversion to general anesthesia. After tracheal extubation, she exhibited bilateral leg weakness that did not resolve over the next 4–6h. An urgent magnetic resonance imaging scan revealed a normal spine with no evidence of hematoma. The lower extremity paresis persisted and a neurologist diagnosed psychogenic paresis, a type of conversion disorder. Interestingly, the patient’s postoperative leg paresis was not her first occurrence of neurological dysfunction after dural puncture. At 27weeks of gestation, she had similar lower extremity symptoms after a lumbar puncture, performed to exclude meningitis for severe headache symptoms. Psychogenic paresis is not commonly reported in the medical literature and we found no reports of psychogenic paresis after spinal anesthesia in a parturient or recurrent psychogenic paresis. We review the various risk factors, etiology, neurological signs and symptoms, types, therapy and future management of a patient with recurrent conversion disorder.

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Case Reports: Introduced in 1998, the bispectral index (BIS) helps anesthesiologist monitor neurological awareness by computer processed EEG recordings that essentially calculate the depth of anesthesia, however other studies and case reports indicate that BIS can be helpful in other ways by assessing underlying neurologic perfusion, function, and even neurological outcomes when employed in traumatic brain injury cases. BIS is currently widely used during cardiac surgeries requiring cardiopulmonary bypass in which patients are at a higher risk of awareness, yet research shows that more important brain perfusion and neurologic information can be gathered in complicated cases. We present a case of a 58yo male with severe symptomatic aortic stenosis with an estimated echo peak gradient of 100mmHg and a calculated valve area of 0.6cm2 who underwent an aortic valve replacement, mitral valve repair, and tricuspid valve annuloplasty with intraoperative BIS values that fell and remained close to zero at the start of cardiopulmonary bypass (CPB) and aortic cross clamping. Normal flow in the aortic arch was confirmed by transesophageal echocardiogram and there was no evidence of hematoma or dissection. Pressure distal to the clamp felt normal. Pump perfusion pressures and flow were normal. The surgical case was continued. Cerebral saturations were 64% at CPB and dropped to 58% by the end of the case. Post operatively the patient remained unresponsive and the following day this prompted further neurological testing. A head CT showed infarction of the posterior fossa with compression of the fourth ventricle and multiple supratentorial infarcts with compression of the ventricular system and effacement of the sulci suggesting a diagnosis of brain death. Finally, full neurological testing confirmed a diagnosis of brain death secondary to massive embolic strokes that likely occurred during the intraoperative period correlating to BIS recordings. Discussion: This case illustrates that low BIS values should prompt a full intraoperative neurological assessment and aggressive treatment in order to diagnose and treat intracerebral pathology in a timely manner.

Epidural inflammatory pseudotumor in the thoracic spine in a patient with polymyalgia rheumatica

Only six previous cases of epidural inflammatory psedotumor in the spine have been reported. None of them were seen in the course of polymyalgia rheumatica (PMR). To describe a rare case of epidural inflammatory pseudotumor in the thoracic spine in a patient with PMR. Case report. A 63-year-old man had a 6-year history of PMR treated with prednisone and cyclosporine. He presented with gait disturbance. Magnetic resonance imaging on the 12th day after the onset of the symptoms showed spinal cord compression caused by a posterior epidural mass at the T5-T6 level. The patient underwent a T5-T6 laminectomy and a total excision of the mass, which involved the ligament flavum and epidural adipose tissue and firmly attached to the dura mater. Histopathologic examination revealed severe lymphoplasmacytic infiltration with fibrosis in the entire specimen and no evidence of hematomas or tumorous lesions. After surgery, the patient's neurologic symptoms disappeared immediately. Two years after surgery, the patient is neurologically normal and has not had a recurrence. This report identifies a rare case of epidural inflammatory pseudotumor in the thoracic spine in a patient with PMR.

Transverse myelitis following combined spinal-epidural anesthesia

Transverse myelitis following combined spinal-epidural anesthesia

Acute Subdural Hematoma Without Subarachnoid Hemorrhage Caused by Ruptured A1-A2 Junction Aneurysm

A 54-year-old man was admitted to our hospital with complaint of sudden headache. The patient had suffered two episodes of transient headache before admission. Computed tomography (CT) revealed acute subdural hematoma (ASDH) on the right side of the cerebral convexity with bilateral extension along the tentorium cerebelli without signs of subarachnoid hemorrhage (SAH) or intracerebral hemorrhage (ICH). Three-dimensional CT angiography and conventional cerebral angiography revealed a left A1-A2 junction aneurysm. Neck clipping of the aneurysm was performed. The aneurysm extended inferiorly, with the dome embedded in the chiasmatic cistern and tightly adhered to the arachnoid membrane. There was no evidence of hematoma in the subarachnoid space. The patient was discharged without neurological deficit. Ruptured aneurysms resulting in ASDH without SAH or ICH are very rare. Radiological investigation such as three-dimensional CT angiography should be performed to find the causative aneurysm in a patient with ASDH with a history of repeated headaches and without traumatic signs or episodes, and the appropriate treatment should be planned with expediency.

Outpatient mastectomy clinical pathway.

144 Background: Many patients require hospitalization after mastectomy, predominantly for pain management and treatment of postoperative nausea and vomiting (PONV). In order to improve a woman's perioperative experience after mastectomy and facilitate mastectomy on an outpatient basis, we initiated a clinical pathway for perioperative management of unilateral mastectomy patients at Mayo Clinic Rochester. Methods: The clinical pathway consists of preoperative oral medications (celecoxib and gabapentin), preoperative ultrasound guided paravertebral block using bupivacaine, intraoperative anesthesia management with total intravenous anesthetic, and minimal use of long-acting opioids and postoperative acetaminophen and oxycodone. All patients are evaluated by the surgical team on the afternoon after surgery and if patients are recovering well are discharged on the day of surgery. The following morning, the surgical team telephones the patient to follow up on management of pain, nausea or vomiting, and drain output. Results: Eighteen patients have been treated on this clinical pathway. Mean age of patients was 66 (range 51-81). Majority of patients (n=16, 89%) underwent unilateral mastectomy with sentinel lymph node biopsy, with 1 patient undergoing bilateral mastectomy and 1 patient undergoing mastectomy and axillary dissection. All patients are evaluated by the surgical team on the afternoon of surgery. Fourteen patients (78%) were without evidence of hematoma or PONV, pain was well-controlled on oral medications and they were discharged on the day of surgery. On morning after telephone calls, pain scale ratings ranged from 1 to 3 and no patients verbalized complaints of nausea. Four patients (22%) treated on this clinical pathway required overnight observation in the hospital, one for urinary retention, two for pain control, and one for high sanguineous drain output. Conclusions: The clinical pathway presented provides preemptive analgesia and regional anesthesia for patients undergoing mastectomy, enabling the majority of patients to be discharged on the day of surgery. The clinical pathway is a safe and effective way to improve the perioperative experience of breast surgery patients and decrease hospital admission.

Carotid artery pseudo-pseudoaneurysm after excision of carotid body tumor

A 37-year-old woman was referred for evaluation of a carotid body tumor. The patient gave a history of right neck fullness for several months before the mass was identified on physical examination during an evaluation for benign biliary disease. The lesion was initially diagnosed by computed tomography angiogram (CTA) and confirmed with duplex ultrasound imaging, which revealed a 4-cm vascular mass intimately associated with the internal and external carotid arteries. She underwent surgical excision of this tumor as well as a modified radical lymph node dissection due to the presence of several enlarged nodes along the right jugular chain. A CTA of the head and neck was preformed postoperatively after the patient complained of a severe headache. This diagnosed a 2-cm pseudoaneurysm of the external carotid artery near the carotid bifurcation (A/Cover; B). The patient underwent a second neck exploration, and the carotid arteries were intact with no evidence of hematoma or pseudoaneurysm. In the approximate location where the pseudoaneurysm had been seen on the CT scan, there was a small amount of clear fluid characteristic of lymph that was associated with soft, crescent-shaped gelatinous material that appeared to be proteinaceous. The fluid was aspirated, and the proteinaceous material was examined with fluoroscopy and found to be radiopaque (C). The volume of the fluid along with the crescent-shaped material approximated the size of the pseudoaneurysm.

Pre-closure of femoral venous access sites used for large-sized sheath insertion with the Perclose device in adults undergoing cardiac intervention

Background: Interventional procedures in adults with congenital cardiac conditions often require insertion of large-sized sheaths into the femoral veins. Data on the use of suture-mediated devices for femoral venous access...

The safety and efficacy of the StarClose® vascular closure system: The ultrasound substudy of the CLIP study

The StarClose Vascular Closure System (Abbott Vascular, Redwood City, CA) features a nitinol clip that is designed to achieve closure of the femoral arteriotomy access site. The CLIP Study was performed to assess the safety and efficacy of StarClose when compared with standard manual compression following 5-6 French diagnostic or interventional percutaneous procedures. A substudy of this trial was designed to assess the utility of duplex ultrasonography to assess patency of the femoral artery and to determine access site complications (pseudoaneurysm, arteriovenous fistula, hematoma, deep vein thrombosis) in a multicenter prospective trial. This is the report of the duplex ultrasound (DUS) substudy of the CLIP trial. A total of 17 U.S. sites enrolled 596 subjects with 483 subjects randomized at a 2:1 ratio to receive StarClose or manual compression of the arteriotomy after a percutaneous procedure. The study included roll-in (n = 113), diagnostic (n = 208), and interventional (n = 275) arms with a primary safety endpoint of major vascular complications through 30 days and a primary efficacy endpoint of postprocedure time to hemostasis. A substudy of the CLIP interventional arm evaluated DUS images of the closure site at five study sites, targeting 100 subjects at day 30 following hemostasis. The DUS protocol was devised and implemented by an independent vascular ultrasound core laboratory with extensive experience in vascular device trials. DUS inguinal region from 6 cm proximal to 6 cm distal to the arteriotomy puncture was performed. A qualitative examination was performed to determine the presence of iatrogenic vascular injuries: hematoma, pseudoaneurysm (PSA), arteriovenous fistula (AVF), and arterial/venous thrombosis or stenosis using 2-dimensional gray scale, color, and focused Doppler images. DUS of 96 subjects randomized to StarClose (n = 71) and compression (n = 25) were performed and evaluated. There was no evidence of hematoma, PSA, or AVF observed in the StarClose group. No StarClose subjects in the substudy had a PSA or AVF. All patients in the substudy demonstrated patency of the access site artery and vein without thrombosis or stenosis. Finally, in the entire study cohort, no clinically-driven DUS studies demonstrated iatrogenic vascular injury or vessel thrombosis in the StarClose treated patients. DUS, a safe and reliable method for determining the safety and efficacy of access site closure devices, is a reliable, safe, inexpensive and accurate method of assessing vascular access site complications in multicenter trials. In this substudy of the CLIP study, DUS found no statistical difference in access site complications between the StarClose and manual compression groups. Both groups maintained vessel patency without stenosis, thrombosis, hematoma, pseudoaneurysm, or AV fistula.