Protamine Induced Anaphylactic Shock after Peripheral Vascular Surgery

Severe noncardiogenic pulmonary edema after cardiopulmonary bypass: Case report

Lung injury is a common complication after cardiopulmonary bypass (CPB). However, cases of noncardiogenic pulmonary edema in which the patient ultimately requires extracorporeal membrane oxygenation (ECMO) support are uncommon. A 54-year-old man was admitted to the hospital with shortness of breath after activity and paroxysmal dyspnoea at night for 3 months. Infective endocarditis and acute heart failure were diagnosed. The patient underwent emergency surgery including aortic valve replacement, mitral valve replacement, tricuspid valve repair, and ventricular septal defect correction. It's noteworthy that the patient experienced significant pulmonary edema during the surgery and within 8 hours postoperatively, with over 3000 mL of yellow-clear fluid aspirated from the trachea and bronchi. The patient eventually recovered through ECMO V-V mode treatment. Inflammatory markers were markedly elevated during the perioperative period, and blood smear revealed Gram-positive bacterial infection. Blood NGS testing detected Streptococcus pneumoniae infection. Despite various factors contributing to the patient's pulmonary edema, it is hypothesized that the edema is related to uncontrolled inflammatory response and cytokine storm. Therefore, when significant pulmonary edema occurs during surgery, swift and decisive actions are necessary to avoid missing the optimal rescue window. If required, the use of ECMO is an effective final treatment option.

Access Site Complications Are Uncommon with Vascular Closure Devices or Manual Compression after Lower Extremity Revascularization

OBJECTIVE

Vascular closure devices (VCD) and manual compression (MC) are used to achieve hemostasis following peripheral vascular interventions (PVI). We sought to compare perioperative outcomes between MC and four VCDs following PVI in a multicenter setting.

METHODS

The Vascular Quality Initiative was queried for all lower extremity (LE) PVIs with common femoral artery access performed from 2010-2020. VCDs included were MynxGrip® (Cordis, Santa Clara, CA, USA), StarClose SE™ (Abbott, Redwood City, CA, USA), Angio-Seal® (Terumo, Somerset, NJ, USA), and Perclose ProGlide™ (Abbott, Redwood City, CA, USA). In a blinded fashion, these four VCDs (A, B, C, D) were compared to MC for baseline characteristics, procedural details, and outcomes (access site hematoma and stenosis/occlusion). Sheath size >8 Fr were excluded. Propensity score matching (1:1) was performed. Univariable and multivariable analyses were completed for unmatched and matched data.

RESULTS

There were 84,172 LE PVIs identified: 32,013 (38%) used MC and 52,159 (62%) used VCDs (A-12,675;B-6,224;C-19,872;D-13,388). Overall, average age was 68.7 years and 60.4% were male; indications for intervention were most commonly claudication (43.8%) and tissue loss (40.1%). When compared to MC, VCDs were utilized more often in patients with obesity, diabetes, and end stage renal disease (all P<.001). VCDs were used less often in patients with hypertension, chronic obstructive pulmonary disease, coronary artery disease, prior percutaneous coronary and extremity interventions, and major amputation (all P<.001). VCD use was more common, compared to MC, during femoral-popliteal (73% vs. 63.8%) and tibial interventions (33.8% vs. 22.3%), but less common with iliac interventions (20.6% vs. 34.7%) (all P<.001). Protamine was used less often after VCDs (19.1% vs. 25.6%, P<.001). Overall, there were 2,003 (2.4%) hematomas of which 278 (13.9%) required thrombin/surgical intervention. When compared to MC, any VCD use had fewer hematomas (1.7% vs. 3.6%, P<.001) and hematomas requiring intervention (.2% vs. .5%, P<.001). When divided by hemostatic technique, any hematoma were MC-3.6%; A-1.4%; B-1.2%; C-2.3%; D-1.1%, P<.001. Hematomas requiring intervention were MC-.5%; A-.2%; B-.2%; C-.3%; D-.1%, P<.001. Access site stenosis/occlusion was similar between MC and any VCDs (.2% vs. .2%, P=.12). Multivariable analysis demonstrated that any VCDs and individual VCDs, vs. MC, were independently associated with fewer hematomas. Access site stenosis/occlusion was similar between any VCDs and MC. Matched analysis revealed similar findings.

CONCLUSIONS

Although overall rates of hematomas requiring intervention were low regardless of hemostatic technique, VCD use, irrespective of type, compared favorably to MC with significantly fewer access site complications after PVI.