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A 58-year-old woman presented with gangrene of the left upper arm stump caused by an arteriovenous malformation originating from the subclavian artery. She had been treated unsuccessfully in the past with repeated attempts of coil embolization and debridement, but finally she underwent arm amputation. A 14 mm diameter occlusion self-expandable stent was placed in the left subclavian artery via ipsilateral brachial artery access, with immediate and complete interruption of arterial supply to the vascular malformation. This minimally invasive treatment provides an alternative method of management of arteriovenous malformations in the subclavian region. Vascular

Can J Surg

Surgical management of coexisting severe coronary artery disease and large or symptomatic abdominal aortic aneurysm may be required in patients who are unsuitable candidates for minimally invasive interventions. Although several options have been proposed, the optimal timing to deal with both entities, in order to achieve the best outcome, is still debatable. This report presents a modified approach based on a two-stage treatment in a single anesthetic session. J Card Surg

BACKGROUND: The aim of this study was to investigate pancreatic injury after 45 min of thoracoabdominal aortic occlusion in a porcine model. METHODS: Twenty-four pigs were used. Six pigs underwent sham operation and 18 intravascular balloon thoracoabdominal aortic occlusions for 45 min. The animals were randomly killed at 12, 48 and 120 h after reperfusion. After killing, all pancreata were examined macroscopically for any signs of acute pancreatitis, whereas gland specimens were harvested for histological study to evaluate pancreatic injury (haematoxylin and eosin staining) and acinar cell apoptosis (Terminal deoxynucleotidyl transferase mediated dUTP Nick-End Labelling staining). RESULTS: Pancreatic injury severity score was mildly increased in terms of oedematous features at 12 h after reperfusion, but normalized to sham levels by the second day and thereafter. Necrotic injury was not statistically significant at any time point. Acinar cell apoptotic index was mildly increased at 12 and 48 h, but showed a tendency to decrease towards sham levels by the fifth day. One animal developed acute pancreatitis. CONCLUSION: Acute pancreatitis is unlikely to occur after 45 min of thoracoabdominal aortic occlusion. However, an early, mild oedematous and apoptotic injury that occurs subclinically seems to be a constant event. This injury might have clinical significance when combined with pre-existent pancreatic pathologies. ANZ J Surg

Knotting of an epidural catheter leading to entrapment is a rare complication of epidural catheterization. A lumbar epidural catheter inserted in a 28-year-old woman for caesarean section anesthesia and postoperative analgesia proved difficult to remove. After multiple attempts and placing the patient in the same position as when the catheter was initially inserted, the entrapped catheter was dislodged intact, revealing a double knot near its distal tip. Leaving catheters of less than 4 cm in length in the epidural space may help to avoid this complication. It is important the patient be informed of the techniques involved in the extraction of the resistant catheter because patient's cooperation is important for the nonsurgical removal of an entrapped epidural catheter. Acta Anaesthesiol Belg

AIM: Several studies suggest that postoperarive concentrations of cardiac troponin-I (cTnI) may increase in patients undergoing aorto-coronary bypass grafting (CABG). The degree and pattern of release appears to be associated with perioperative myocardial damage. METHODS: This was a prospective observational study with serial sampling conducted at the Departments of Cardiothoracic Surgery and Anesthesiology, University Hospital of Ioannina, Ioannina, Greece. The levels of cTnI and creatine kinase-MB (CK-MB) preoperatively, upon admission to the intensive care unit and at 12, 24, 36 and 48 hours after surgery, as well as daily from postoperative days 3-7 were determined in 41 consecutive patients (33 males and 8 females, aged 64.8+/-6.1 years) who underwent CABG with cardiopulmonary bypass. The Authors compared the patterns and variation of cTnI and creatine kinase (CK)-MB after CABG in patients with or without postoperative cardiac events (PCEs). RESULTS: Eleven patients experienced a PCE (postoperative ventricular and supraventricular arrhythmia, need for intra-aortic balloon pump (IABP) for >12 hours, or postoperative myocardial infarction, [MI]). In patients without PCE the elevation of cTnI peaked at 24 hours after surgery, while in patients with PCE maximal values of cTnI occurred after 36 hours. CTnI levels correlated with CK-MB after the procedure. Receiver-operating characteristic (ROC) curve analysis indicated that cTnI is superior to CK-MB with regard to PCE diagnosis following CABG (area under the ROC curve, 0.73, 95% CI (0.53-0.93) versus 0.54, 95% CI, (0.25-0.83). CONCLUSION: CTnI seems to be more valuable compared to CK-MB in the detection of PCEs in patients undergoing coronary surgery. J Cardiovasc Surg (Torino)

End-stage renal diabetic patients undergoing dialysis through an arteriovenous graft (AVG) often present with multiple graft complications which demand a combined therapeutic approach. We report a case of a male suffering from a pseudoaneurysm and venous outflow stenosis of his thigh AVG, as well as from critical limb ischemia caused by multiple significant stenoses of the femoropopliteal arterial segment. The patient was managed in a single session with a combination of classic open surgical and endovascular techniques in order to treat his aneurysm, salvage the AVG and to revascularize his leg. This case illustrates the prospect of combining classic open surgical and endovascular techniques for the optimal management of complicated AVGs. Using the hybrid approach in these cases one can succeed in optimizing the result, while simultaneously minimizing the overall risk for the patient. J Vasc Access

Four patients suffering from concomitant descending thoracic pathology and abdominal aortic aneurysms were treated with endovascular stent-grafts simultaneously. Graft deployment was successful and uneventful in all patients. Paraplegia was not observed. One patient developed an abdominal type Ib endoleak at 12 months which was repaired endovascularly. One patient died from multiorgan failure 3 days after the deployment of the grafts. After 18, 36 and 42 months follow up all the other patients are well without any graft related complication. Simultaneous endovascular repair for coexisting descending thoracic and abdominal aortic pathologies might be an acceptable alternative to open surgery or hybrid operations, at least for the high risk patients. Int Angiol