The Bird's Nest inferior vena caval filter: review of a single-center experience

PURPOSE

To examine a large single-center experience with Bird's Nest vena caval filters for indications, clinically evident recurrent thromboembolic disease, and other filter-related complications.

MATERIALS AND METHODS

During a 6-year period, 308 patients underwent percutaneous placement of an inferior vena caval filter. The 267 patients who received a Bird's Nest filter are the subject of this retrospective review. The series included 162 men and 105 women who ranged in age from 16 to 88 years (mean, 57.1 +/- 17.0 standard deviation).

RESULTS

Indications for filter placement included contraindication to anticoagulation (n = 141), complication of anticoagulation (n = 23), failure of anticoagulation (n = 30), failure of previously placed filter (n = 1), and prophylaxis (n = 82). Ten patients had more than one indication. Acute lower extremity deep venous thrombosis was confirmed in 133 patients, pulmonary embolism (PE) was found in 44 patients, and both were positively diagnosed in 37 other patients. Fifty-three patients had no documented acute thromboembolic disease at the time of insertion. Mean follow-up was 13 months. Thirty-day mortality was 9.7%, including one death from recurrent PE and one major puncture-site bleeding episode that may have contributed to death. Recurrent PE was found at radionuclide scanning or autopsy in three patients (1.1%), whereas another eight patients (3.0%) had suspected recurrent PE without confirmatory studies. Eight patients (3.0%) developed early venous access site thrombosis, including two who progressed to phlegmasia cerulea dolens with fatal complications. Significant nonthromboembolic problems were encountered in 1.9% of patients.

CONCLUSIONS

The Bird's Nest filter is a safe and effective device for patients with complicated venous thromboembolic disease.

An unusual complication of T-tubes

The morbidity of long-term ventilation tubes (Goode T-tubes) is often discussed with reference to otorrhoea, tympanosclerosis and long-term perforation. We report three cases of the T-tube slipping into the middle-ear cleft. In two of the three patients this was asymptomatic and the T-tubes were left in situ. In the third patient this complication was documented on three occasions when the T-tube was removed and reinserted for recurrent effusions. We are unaware of this complication being previously reported in the literature.

Catheter fragments embolization

Although the use of central venous silicone catheters is widespread, little is known about the incidence of catheter rupture and embolization. Over a three-year period, 3916 silicone catheters were inserted in 3672 patients in the authors' hospital. Catheter or catheter fragments embolism occurred in 4 patients (1.2 embolizations per 1000 patients treated). Inappropriate mechanical deobstruction attempts resulted in 2 embolizations, and hence, these should be avoided. Chest roentgenography failed to detect the small fragments within the heart silhouette in 2 cases. Two-dimensional echocardiography showed the separated catheter fragment in all 4 cases. All four catheter fragments were subsequently removed from the right-heart chambers.

Accidental swallowing of endodontic instruments

Swallowing or aspiration of a foreign body is a complication that may arise from any procedure in the oral cavity performed without the use of a rubber dam. Two cases of swallowed endodontic instruments and possible complications are presented. Emphasis is given in the discussion on the early diagnosis and treatment and primarily on prevention with the use of rubber dam, an absolute essential during endodontic treatment.

Heavy metal: beware

A 19-year-old Crouzon's syndrome patient with a history of multiple craniofacial procedures presented with severe bilateral temporal and frontal depressions and metal implants protruding through the scalp in multiple locations. Preoperative analysis revealed an extensive cranial defect that had been reconstructed with multiple large metallic mesh implants. The mesh required complete removal with an autograft cranial reconstruction. We present this case to urge that caution and forethought be exercised when contemplating the use of metallic alloplasts for major craniofacial reconstructions.

[Intravesical migration of an artificial urinary sphincter AMS-800: a rare complication]

Presentation of two cases of a patients with urinary incontinence of neurogenic origin treated by means of an artificial urinary sphincter graft AMS-800 who suffered the complication of intravesical migration of the occlusive cuff in one case, and pressure balloon and occlusive cuff in the second one. In the latter, the pressure balloon underwent a process of intravesical calcification. A review of the literature on the etiopathogeny of this complication and management of these patients is conducted.

Complications associated with pectoral cardioverter-defibrillator implantation: comparison of subcutaneous and submuscular approaches. Worldwide Jewel Investigators

OBJECTIVES

The aim of this study was to compare complications in a large cohort of patients undergoing pectoral cardioverter-defibrillator implantation with a subcutaneous or submuscular approach.

BACKGROUND

Pectoral placement of implantable cardioverter-defibrillator (ICD) pulse generators is now routine because of downsizing of these devices. subcutaneous implantation has been advocated by some because it is a simple surgical procedure comparable to pacemaker insertion. Others have favored submuscular insertion to avoid wound complications. These surgical approaches have not been compared previously.

METHODS

The subjects for this study were 1,000 consecutive patients receiving a Medtronic Jewel ICD at 93 centers worldwide. Cumulative follow-up for all patients was 633.7 patient-years, with 64.9% of patients followed up for > or = 6 months. The complications evaluated were erosion, pocket hematoma, seroma, wound infection, dehiscence, device migration, lead fracture and dislodgment.

RESULTS

Subcutaneous implantation was performed in 604 patients and submuscular implantation in the remaining 396. The median procedural times were shorter for subcutaneous implantation (p = 0.014). In addition, the cumulative percentage of patients free from erosion was greater for subcutaneous implantations (p = 0.03, 100% vs. 99.1% at 6 months). However, lead dislodgment was more common with subcutaneous implantations (p = 0.019, 2.3% vs. 0.5% at 6 months) and occurred primarily during the first month postoperatively. Overall, there were no significant differences in cumulative freedom from complications between groups (4.1% vs. 2.5%, p = 0.1836).

CONCLUSIONS

Subcutaneous pectoral implantation of this ICD can be performed safely and has a low complication rate. This approach requires a simple surgical procedure and, compared with the submuscular approach, is associated with shorter procedure times and comparable overall complication rates. However, early follow-up is important in view of the increased lead dislodgment rate.

Portal vein graft rectal evacuation after Whipple procedure. the Fabrizio's disease

In selected cases, pancreatic resections may be performed "en bloc" with arterial and/or venous segments, which have to be replaced with autologous or synthetic grafts. Rectal evacuation of portal vein graft following a Whipple procedure is described, being a late graft infection supposed to underlie this event. Portal vein graft rectal evacuation has not previously been reported in the literature and it is worth keeping it in consideration when performing a regional pancreatectomy.

Erosion of internal cardioverter defibrillator pocket and migration of pulse generator into the peritoneal cavity

ICD therapy for life-threatening arrhythmias is well established. As more patients are treated, the incidence of recognized and new complications may increase. We report ICD pocket erosion and migration of the pulse generator into the peritoneal cavity in two patients.

Localization of impalpable breast lesions--a surgical approach

The conventional approach to localization of impalpable breast lesions, i.e. employing a hooked wire with either stereotaxis or a perforated plate, has potential disadvantages for the operating surgeon. Often the entry point of the wire lies some distance from the site of projection of the lesion on the skin. The guide-wire should pierce the skin at, or close to, the site of any proposed surgical incision and proceed along the shortest and most direct course towards the lesion. Ideally, the wire should lie within a radial distance of between 1 and 2 cm from its target. A method is described which achieves these objectives and involves both radiological and clinical measurements. A total of 665 guide-wire localized biopsies have been carried out at the above institutions between 1 November 1987 and 31 March 1995 and between 1 January 1994 and 31 March 1996. In only 4% of cases was re-positioning of the wire required. Excision of the radiological lesion was obtained with a single biopsy in 99% of cases. A second or third biopsy was indicated in 0.7% and 0.3% of cases, respectively. Migration of the wire occurred in two patients and no cases of wire transection or pneumothorax were reported. This method of localization facilitates subsequent excision and permits the most appropriate incision consistent with optimal cosmesis.

Biomechanical analysis of location of lag screw of a dynamic hip screw in treatment of unstable intertrochanteric fracture

OBJECTIVE

The aim of this study was to assess the most adequate location of a lag screw of a dynamic hip screw in the treatment of an unstable intertrochanteric fracture.

METHODS

Six pairs of proximal femora obtained from fresh adult cadavers were inflicted with iatrogenic unstable intertrochanteric fractures. Fractures of both sides were stabilized with two different favored locations of a lag screw and tested by a Material Testing System machine with increased loads to evaluate the relative migration of the femoral head.

RESULTS

There was significant difference (p < 0.05) with less migration of the femoral head by inferior insertion of a lag screw in the frontal plane and central insertion in the coronal plane.

CONCLUSIONS

Based on theoretical and experimental considerations, the most adequate location of a lag screw of a dynamic hip screw should be inferior in the frontal plane and central in the coronal plane.

Arterial bullet embolism resulting in delayed vascular insufficiency: a rationale for mandatory extraction

This paper reports a case of migrating intravascular bullet embolus that initially produced no symptoms but resulted in an above-knee amputation 14 months after its entry into a peripheral artery. The missile entered through a penetrating gunshot wound to the abdominal aorta and later became lodged in the left popliteal artery. However, the bullet fragment migrated further into the posterior tibial artery with consequent vascular insufficiency requiring a supracondylar amputation of the left lower extremity 14 months later. Emphasis is placed on the need for a high index of suspicion for bullet embolism, aggressive search for any bullets unaccounted for, and early surgical removal of all confirmed arterial emboli.

[Peritoneal migration of defibrillator implanted behind the rectus abdominis]

Automatic Implantable Cardioverter Defibrillator (AICD) has become a therapeutic option to malignant ventricular tachyarrhythmias. Its bulky device responds for discomfort and the likelihood of generator extrusion or migration, when implanted under the subcutaneous tissue. Among alternative sites, pre-peritoneal location has several advantages but hides its own risks. We present a generator peritoneal migration from a pocket made behind the rectus abdominis.