American journal of surgery
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Comparative Study
Duplex ultrasound insertion of inferior vena cava filters in multitrauma patients.
Techniques for placement of inferior vena cava (IVC) filters have undergone continued evolution from open surgical exposure of the venous insertion site to percutaneous insertion in most cases today. However, the required transport either to an operating room or interventional suite can be complex and potentially hazardous for the multiply injured trauma patient who may require ventilator support, controlled intravenous infusions, or skeletal immobilization. Increased experience with color-flow duplex scanning for routine IVC imaging and portability of ultrasound equipment have suggested the usefulness of duplex-guided IVC filter insertion (DGFI) in critically ill trauma and intensive care unit (ICU) patients. ⋯ Vena caval interruption can be safely performed under ultrasound guidance in a monitored, ICU environment. In selected multiply injured trauma patients, this will reduce the risk, complexity and cost of transport for these critically ill patients. DGFI also reduces procedural costs compared with an operating room or interventional suite, and eliminates intravenous contrast exposure. Preprocedural scanning is essential to identify patients suitable for DGFI, and careful attention must be paid to the known ultrasonographic anatomical landmarks.
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Intra-arterial thrombolytic therapy is currently a therapeutic option for the treatment of acute limb ischemia. A recent large prospective randomized trial (TOPAS) comparing lytic therapy and operative intervention showed that both forms of treatment had similar results in terms of amputation-free survival. However, the exact role for lytic treatment is unclear. ⋯ Thrombolysis with urokinase simplified the treatment of native arterial occlusion proving to be the sole therapy in 18 (29%) patients or a valuable adjunct by facilitating the angioplasty of arterial lesions and avoiding open surgery in 60% of patients treated. In addition, the correction of inflow lesions reduced the magnitude of required subsequent bypass procedures to achieve limb salvage. In conclusion, successful thrombolysis of native artery occlusion provided durable arterial patency and limb salvage, particularly in patients with new onset claudication.
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Silicone venous access devices (VADs) are commonly used for multiple intravenous infusions and blood sampling in chronically ill patients, particularly cancer patients. These devices are susceptible to malfunctions most commonly characterized by difficulty infusing fluids or withdrawing blood. We hypothesized that the incidence of such malfunctions is primarily related to the position of the catheter tip relative to the superior vena cava/right atrial junction. ⋯ These results indicate that malfunctions can be minimized in silicone venous access catheters by locating the catheter tip as close to the superior vena cava/right atrial junction as possible, or slightly inside the right atrium. To ensure proper location of the catheter tip, placement should be performed under fluoroscopy, and a radiograph should be obtained immediately following placement, with the patient in the upright position.
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The time required for air leak resolution after chest trauma is not well described. Based on an institutional review of posttraumatic air leaks our hypothesis was that video-assisted thoracic surgery (VATS) for persistent posttraumatic air leak would decrease chest tube days and length of stay compared with nonoperative management. ⋯ In patients otherwise ready for discharge VATS reduces chest tube days and length of stay when used to treat persistent posttraumatic air leak.
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Clinical Trial
Routine preoperative lymphoscintigraphy is not necessary prior to sentinel node biopsy for breast cancer.
This prospective study was performed to ascertain the added benefit of lymphoscintigraphy to a standard method of intraoperative lymphatic mapping and sentinel node biopsy for breast cancer. ⋯ Preoperative lymphoscintigraphy adds little additional information to intraoperative lymphatic mapping, and its routine use is not justified.