Several case series using endovascular techniques in combination with pharmacologic therapy have been reported recently. It should be emphasized, however, that any evidence of bowel ischemia or infarction precludes the use of thrombolytic therapy. At this time, these techniques have been attempted in very early, cases of AMI, and the role of such procedures remains to be determined [51, 52]. Other contraindications to thrombolytic therapy include recent surgery, trauma, cerebrovascular or gastrointestinal bleeding, and uncontrolled hypertension [53].
A total of 219 patients were analysed from the computer database of a single vascular surgical practice. A subset of 63 patients, treated over the latter 4 years of the study, had a detailed assessment and evaluation of the anomalies seen at surgery. This is reported separately.
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We can conclude from this cohort of patients that there is always an underlying cause for the patients' symptoms, usually an anatomical abnormality. The majority of these anomalies are abnormalities of the brachial plexus. All patients with neurogenic TOS should therefore be considered as having 'true neurogenic TOS'. There is often more than one abnormality, even if subtle, making it likely that the pathology is multifactorial. For example, symptoms may develop in a person with an abnormal brachial plexus configuration that may become compressed later in life by muscle spasm or fibrosis after intense sport or a neck injury. In addition to this, the abnormality may only be detected by careful inspection of the anatomy at surgery. A supraclavicular approach is preferred, as a transaxillary approach precludes clear depiction of the neurovascular structures.
The consultants and ASA members agree that, when unintended cannulation of an arterial vessel with a large-bore catheter occurs, the catheter should be left in place and a general surgeon or vascular surgeon should be consulted. When unintended cannulation of an arterial vessel with a large-bore catheter occurs, the SPA members indicate that the catheter should be left in place and a general surgeon, vascular surgeon, or interventional radiologist should be immediately consulted before deciding on whether to remove the catheter, either surgically or nonsurgically, as follows: 54.9% (for neonates), 43.8% (for infants), and 30.0% (for children). SPA members indicating that the catheter may be nonsurgically removed without consultation is as follows: 45.1% (for neonates), 56.2% (for infants), and 70.0% (for children). The Task Force agrees that the anesthesiologist and surgeon should confer regarding the relative risks and benefits of proceeding with elective surgery after an arterial vessel has sustained unintended injury by a dilator or large-bore catheter.
When unintended cannulation of an arterial vessel with a dilator or large-bore catheter occurs, the dilator or catheter should be left in place and a general surgeon, a vascular surgeon, or an interventional radiologist should be immediately consulted regarding surgical or nonsurgical catheter removal for adults. For neonates, infants, and children the decision to leave the catheter in place and obtain consultation or to remove the catheter nonsurgically should be based on practitioner judgment and experience. After the injury has been evaluated and a treatment plan has been executed, the anesthesiologist and surgeon should confer regarding relative risks and benefits of proceeding with the elective surgery versus deferring surgery to allow for a period of patient observation. 2ff7e9595c
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