Surveillance and follow-up after revascularization for critical limb ischemia

The purpose of a structured and cost-effective surveillance program after surgical or endovascular intervention for critical limb ischemia is to optimize limb salvage and preserve arterial repair function. Surveillance programs should include clinical, vascular laboratory, and radiographic follow-up, and, when a high-grade progressive stenosis is identified, appropriately timed intervention should be performed. Because many patients with critical limb ischemia are older and many are frail with limited mobility, optimizing the durability of arterial intervention and keeping these patients ambulatory is an important factor in retaining an independent lifestyle and quality of life. Despite the importance of surveillance after arterial intervention, there is a lack of consensus in the literature regarding the efficacy of surveillance, how it should be performed, and well-defined evidence-based guidelines. This review provides an up-to-date scrutiny on this topic and provides recommendations for optimal testing methods, limitations of surveillance testing, and when and how to intervene. These recommendations should be considered in the care of the patient with critical limb ischemia, but with the understanding that patients vary widely and care should be individualized.     

Atypical pathologic manifestations of Pneumocystis carinii pneumonia in the acquired immune deficiency syndrome. Review of 123 lung biopsies from 76 patients with emphasis on cysts, vascular invasion, vasculitis, and granulomas

The frequency of atypical pathologic manifestations of Pneumocystis carinii pneumonia (PCP) were studied in 123 lung biopsy specimens from 76 National Institutes of Health patients with the acquired immune deficiency syndrome. The following atypical features were observed: interstitial (63%) and intraluminal (36%) fibrosis, absence of alveolar exudate (19%), numerous alveolar macrophages (9%), granulomatous inflammation (5%), hyaline membranes (4%), marked interstitial pneumonitis (3%), parenchymal cavities (2%), interstitial microcalcification (2%), minimal histologic reaction (2%), and vascular invasion with vasculitis (1%). These atypical features are discussed with emphasis on the significance of cavities, vascular invasion, vasculitis, and granulomas. Immunohistochemical staining with monoclonal antibodies to the 2G2 and 6B8 antigens of P carinii in paraffin-embedded lung biopsy specimens did not indicate any diagnostic advantage over routine methenamine silver stains. This study provides an important reminder that a wide variety of pathologic manifestations may occur in PCP in human immunodeficiency virus-infected patients and that atypical features should be sought in lung biopsies from patients at risk for PCP.     

Carcinoid tumors in the breast

BACKGROUND: Carcinoid tumors in the breast are rare. Most represent metastases from other primary sites, but commonly are mistaken for primary breast lesions. METHODS: A literature search of the English language found 59 cases of carcinoid tumors in the breast, 21 (36%) of which were metastases. RESULTS: We present an additional 3 cases of carcinoid tumors metastatic to the breast and discuss the clinical, radiologic, and pathologic manifestations. CONCLUSIONS: It is important to differentiate between primary breast carcinoid tumor and metastatic disease to the breast because of differences in treatment. All palpable breast masses and mammographically detected lesions should undergo a biopsy examination. In those patients with a known history of carcinoid tumor, pertinent clinical history, and previous surgical specimens should be reviewed to avoid an unnecessary mastectomy. If there is no history of a prior carcinoid tumor, a thorough work-up to look for an occult primary tumor elsewhere should be performed.     

Effect of urgent carotid endarterectomy on operative risk and benefit

Objectives:The time of Carotid intervention for recently symptomatic,severe carotid stenosis which cause a transient ischemic attack or minor stroke is still a controversial issue.Early studies showed that carotid endarterectomy (CEA) caused a high risk if performed within days follow an acute ischemic stroke.However,The National Stroke Strategy posted by UK Department of Health advocated that this situation should be regarded as an emergency procedure,and carotid intervention should ideally be performed within 48 hours.We designed this study to discuss the effect of urgent CEA on operative risk and benefit.Methods: we analyze 12 urgent CEA with primary closure performed during 1996 to 1998.All 12 patients were underwent CEA within 2 weeks,and 2 of them within 2 days.Operative risks and overall benefit from surgery were discussed in relation to the time from the last symptomatic event to CEA.Results: 2 urgent CEA performed in 2 days are recovery uneventful.1 of 12 patients,who underwent urgent CEA within 2 weeks,occurred restenosis after 3 months follow up.No 30-day perioperative recurrent TIA,stroke and death.Conclusions:CEA performed within 2 weeks is feasible and reliable procedure in preventing recurrent TIA and stroke after presenting manifestations.The future aim is to perform CEA within 48 hours after TIA or stroke symptoms.     

Surgical treatment of metastatic disease of the femur

Nearly every malignant neoplasm has been described as having the capability to metastasize to bone. Of the estimated 1.2 million new cases of cancer diagnosed annually, more than 50% will eventually demonstrate skeletal metastasis. Advances in systemic and radiation therapy have led to a considerable improvement in the prognosis of patients with metastatic disease. As a result, orthopaedic surgeons are being asked with increasing frequency to evaluate and treat the manifestations of skeletal metastases. The femur is commonly the site of large impending lesions and complete pathologic fractures. Although the health status of some patients may preclude operative intervention, established pathologic fractures of the femur and metastatic lesions deemed likely to progress to imminent fracture generally should be treated surgically. A rational approach to selection of the proper treatment for these problems includes consideration of the patient's overall medical condition and the type, location, size, and extent of the tumor. Treatment principles are the same regardless of location. A construct should ideally provide enough stability to allow immediate full weight bearing with enough durability to last the patient's expected lifetime. All areas of weakened bone should be addressed at the time of surgery in anticipation of disease progression. To minimize disease progression and possible implant or internal fixation failure, postoperative external-beam irradiation should be considered.     

Embolization as cause of bowel ischemia after endovascular abdominal aortic aneurysm repair

OBJECTIVE: We investigated the incidence, cause, and outcome of large bowel and small bowel ischemia after endovascular abdominal aortic aneurysm (AAA) repair. METHODS: Medical records for all patients undergoing endovascular AAA repair from December 1999 to December 2003 were reviewed. The incidence, cause, and outcome of clinically detected postoperative bowel ischemia were analyzed. RESULTS: Seven hundred two endovascular AAA repairs were performed. In 10 patients (1.4%) acute bowel ischemia developed. Six of these patients sustained concurrent small bowel necrosis, and the remaining 4 had isolated colon ischemia. Seven patients underwent exploratory laparotomy. In 6 of these bowel resection was performed, and in 1 patient the ischemic bowel was unsalvageable. Of the 6 patients with small and large bowel ischemia, 4 had segmental or patchy necrosis, which was separated by normal-appearing intestine, and 1 had extensive ischemia that involved most of the small bowel and the entire colon, with pathologic evidence of microembolization. Three patients had preoperative occlusion of the inferior mesenteric artery. One had unilateral and 1 had bilateral hypogastric artery interruption. Five of the 6 patients with small bowel ischemia had thrombus or atheroma in the proximal aneurysmal necks. All patients with isolated colon ischemia survived. All 6 patients with concurrent small bowel ischemia died. CONCLUSION: The total incidence of clinically evident bowel ischemia after endovascular AAA repair is similar to that after open surgery. However, small bowel ischemia occurs more commonly in patients with endovascular repair, and is associated with extremely high mortality. The direct pathologic evidence and the patterns of segmental, skipped, or patchy ischemia in most patients imply that microembolization has an important role.     

Osteomyelitis in the diabetic foot: diagnosis and management

Neuropathic ulcerations and altered immune function place the diabetic patient at increased risk for polymicrobial osteomyelitis of the foot and ankle. The optimal method for evaluation and management of this difficult condition is controversial, and further studies are needed. Infected ulcers with exposed or palpable bone can be assumed to have underlying osteomyelitis. Although plain film should be ordered in each case, MRI is most often used for evaluation and surgical planning. Difficult cases, such as those associated with Charcot osteoarthropathy, may require labeled leukocyte scanning or bone biopsy to arrive at the diagnosis. A multidisciplinary team approach is best, allowing optimal treatment of all associated conditions that commonly affect patients with diabetes mellitus. Vascular evaluation and intervention are critical in the presence of vascular insufficiency or ischemia. Empiric, usually broad-spectrum antibiotics and meticulous local wound care may achieve remission of mild to moderately severe infections and should be included in all treatment regimens. Severe, infections, ischemia, or sepsis requires an aggressive surgical approach. Bone resection, correction of deformity, or amputation often are necessary and should be done with the goal of salvaging a functional foot.     

Portal venous gas detected by computed tomography: is surgery imperative?

BACKGROUND: Portal vein gas (PVG) has historically been associated with mortality rates of 75% or higher and mandatory abdominal exploration. The following study reassesses the clinical significance of gas in the portal venous system detected by computed tomography (CT) and reevaluates the need for surgical intervention in that setting. METHODS: We performed a retrospective chart review of 26 patients presenting with gas in the portal venous system as imaged by CT between August 1, 1993 and April 8, 2001. Characteristics assessed included age, sex, clinical presentation and course, additional CT findings, diagnosis, surgical versus non-surgical management, surgical findings, pathologic correlation, and mortality. RESULTS: Of the 26 patients who had gas in the portal venous system by CT, 11 underwent surgery to determine underlying pathology. Of those who underwent surgery, 8 survived to be discharged while 3 died (73% surgical survival). The survivors presented with gastrointestinal related signs/symptoms and were found at the time of surgery to have adhesions, non-surgically treated inflammation, unclear pathology, or resectable lesions. Those who died all demonstrated marked bowel ischemia intraoperatively. Among patients who did not undergo surgery, 9 survived and 6 died (60% nonsurgical survival). Those who survived presented either asymptomatically or with pathology including acute pancreatitis, recent hypotensive episode, uncomplicated diverticulitis, unresectable colon cancer, or infectious etiology. Those who died were poor surgical candidates or status postvascular procedure. The overall survival in patients with portal venous gas by CT was 65%. CONCLUSION: Portal venous gas on CT is associated with a wide range of pathologies that do not necessarily warrant surgical management. Clinical presentation should be correlated with the presence of PVG and other associated CT findings prior to deciding whether surgery should be performed.     

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目的 探讨Mirizzi综合征的诊断及外科手术治疗的术式。方法 回顾性总结分析28例Mirizzi综合征病的临床资料。结果 28例病人分别行胆囊切除或部分胆囊切除，直接瘘口修补或胆囊补片修补及Rouxen-Y 式肝总管十二指肠吻合术或空肠吻合术。所有病人均痊愈出院。结论 术前明确诊断可减少Mirizzi综合征术中胆道损伤的发生率，手术方式依据病理分型而定。内镜逆行性胰胆管造影（ERCP）及B超是术前明确诊断的主要手段。     

Successful treatment of Buerger's Disease with intramedullary K-wire: the results of the first 11 extremities.

OBJECTIVE: This study describes a new technique for treatment of Buerger's disease, developed to stimulate angiogenesis, using a Kirschner wire placed in the medullary canal of the tibia. The aim of the study was to evaluate clinical and radiological effects of this technique in patients where medical and surgical therapy had failed. MATERIAL AND METHODS: Eleven extremities (six patients) with Buerger's disease were treated with the intramedullary Kirschner wire technique. Inclusion criteria were chronic critical ischemia, Rutherford Grade II or III, with major arterial occlusion shown by Doppler examination and angiography; failure to respond to non-surgical and surgical treatment; and the need for strong analgesics. RESULTS: The mean follow-up time was 19 months (range, 13-25 months). Satisfactory remission in each patient was obtained within 6 weeks of intervention. A significant improvement in clinical manifestations including reduced rest pain and increased claudication distance was observed. Foot ulcers completely healed after Kirschner wire intervention. CONCLUSION: Despite short-term follow-up and small patient series, the intramedullary Kirschner wire technique can be expected to achieve relief of pain and a decrease in major amputations in patients with Buerger's disease in whom medical and surgical therapy had failed. However, comparative studies with longer follow-up should be done to confirm the benefits of this new treatment.     

Operative management of distal ischemia complicating upper extremity dialysis access

BACKGROUND: Ischemia distal to a functioning arteriovenous dialysis access is an infrequent but potentially serious complication that can be difficult to manage while maintaining access patency. METHODS: Retrospective review was made of all patients requiring operative intervention for dialysis access-induced distal ischemia from 1998 to 2002 in a tertiary vascular surgery referral practice. RESULTS: Twelve patients had 13 hands with ischemic changes requiring intervention after placement of hemodialysis access. Ischemia was successfully treated in all cases by distal revascularization-interval ligation. Dialysis access patency was better than expected. CONCLUSIONS: Distal revascularization-interval ligation is the optimal management for dialysis access-induced ischemia and should be attempted whenever possible.     

Multiple isolated aneurysms in a case of "burned out" Takayasu aortitis

Takayasu aortitis (TA) is a chronic inflammatory disease predominantly seen in young Asian women. The disease is idiopathic and largely affects the aorta and its major branches. The basic pathologic changes in TA are fibrosis and subsequent occlusion of the large arteries. TA is classically termed "pulseless" disease, with manifestations during the occlusive stage including limb ischemia, renovascular hypertension, and heart failure. Arterial dilation and aneurysm are largely unappreciated manifestations of TA, but they occur in as many as 32% of affected patients. We report chronic "burned out" TA in a 23-year-old Hispanic woman with isolated aneurysms of the descending thoracic aorta, abdominal aorta, and common iliac arteries, without occlusive disease.     

Transient postictal MRI changes in patients with brain tumors may mimic disease progression

BACKGROUND: Transient postictal imaging abnormalities in patients with non-tumor-related seizures are well documented and include fluid-attenuated inversion recovery/T2 hyperintensity and parenchymal and meningeal contrast enhancement. In contrast, transient postictal imaging abnormalities in patients with tumor-related seizures have been poorly described. Fifty percent of patients with brain tumors have a seizure during the course of their illness and are often imaged after a seizure or after a change in seizure character or frequency. Interval changes on repeat imaging can mimic disease progression or other pathologic processes. METHODS: We describe 3 patients with brain tumors and transient postictal MRI changes that mimicked disease progression and infection. RESULTS: Our patients demonstrated fluid-attenuated inversion recovery/T2 hyperintensity and gadolinium enhancement on MRI studies performed shortly after ictal events. These changes were suspicious for tumor progression in 2 cases and for recurrent infection in the third. Control of seizure activity resulted in resolution of these changes on scans obtained 10 to 21 days later. CONCLUSIONS: Imaging shortly after an ictal event can potentially mislead the clinician to interpret changes as tumor or pathologic progression. Unnecessary intervention in these patients with new and suspicious imaging findings should be avoided. We recommend repeat imaging be performed in patients with brain tumors and seizures several weeks after seizure control if clinically feasible. Further research is needed to delineate the time course of seizure-induced MRI changes.     

儿童紫癜性肾炎的临床和病理研究

目的：探讨儿童紫癜性肾炎（HSPN）的临床和肾组织病理改变特点及其关系。方法：回顾性分析1995年12月～2007年12月进行过肾活检的105例HSPN患儿的临床和肾组织病理改变情况。结果：105例HSPN患儿中,单纯血尿组18例（17.14%）,血尿及蛋白尿组61例（58.10%）,肾病综合征组26例（24.76%）;三组间的Scr、BUN、IgA、IgE、CRP和C3水平均无统计学差异（P均〉0.05）,血浆白蛋白在各组间存在统计学差异（P均〈0.01）。病理上ISKDC分级结果为：Ⅱa级8例（7.62%）,Ⅱb级21例（20.00%）,Ⅲa级33例（31.43%）,Ⅲb级38例（36.19%）,Ⅳ级5例（4.76%）;三组间比较有统计学差异（χ^2=44.51,P〈0.01）。肾小管间质病变的组织学分级结果为：（-）级34例（32.38%）,（＋）级64例（60.95%）,（＋＋）级6例（5.71%）,（＋＋＋）级1例（0.95%）,（＋＋＋＋）级0例（0%）;三组间比较有统计学差异（χ^2=40.59,P〈0.01）。结论：儿童HSPN临床表现多样,肾病理改变相对较轻,且两者之间存在密切关系。     

Idiopathic true brachial artery aneurysm in a nine-month infant

Upper extremity peripheral artery aneurysms are a rarely encountered arterial disorder. Brachial artery aneurysms seen in the pediatric age group are generally trauma resultant. A nine-month-old male infant patient presented with complaints of an asymptomatic mass in the arm. Following Doppler ultrasonography and magnetic resonance imaging (MRI) examinations, saccular aneurysm, originating from the left brachial artery was diagnosed in the patient without history of trauma. The aneurysm was resected by surgical intervention, and primary repair of the brachial artery was performed by end-to-end anastomosis. No complication was observed during the follow-up. Surgical intervention for upper extremity aneurysms should be initiated without delay in order to prevent extremity ischemia and amputation.     

GROWTH DISTURBANCES ASSOCIATED WITH UNTREATED BENIGN BONE CYSTS

Background: The occurrence of benign bone cysts adjacent to an active physis may be associated with a physeal arrest. That arrest may result from physeal penetration of the cysts itself, secondary pathologic fracture or the result of surgical curettage. Methods : The pre-treatment X-rays of patients attending the Bone Tumor Clinic at the Children's Hospital and Medical Center were reviewed. Those patients presenting with a bone cyst were identified and the affected side was compared to the normal side in order to determine growth discrepancies. Results: Three cases of benign bone cysts are presented that were located adjacent to a growing physis and produced growth disturbance in the absence of surgical intervention. Conclusions: The risk of growth disturbance in itself should not be a contraindication to surgical intervention.     

Acute hand ischemia after radial artery cannulation resulting in amputation

Although radial artery cannulation is a common procedure, in rare cases, it can cause thrombosis leading to severe ischemia of the hand and potentially subsequent gangrene resulting in tissue loss. In this case report, a patient who developed a severely ischemic left hand subsequent to radial artery cannulation is presented. Doppler ultrasound studies showed adequate flow in the patient's hand, however complete thrombosis of the radial artery and significant low flow of the ulnar artery were found using arterial angiogram. The ischemia progressed and surgical intervention to revascularize the hand was unsuccessful, which led to the ultimate amputation of the patient's hand. In cases such as these, where Doppler ultrasound findings show flow but the hand ischemia continues to progress, further diagnostic studies and surgical intervention should be performed as soon as possible to minimize the amount of tissue loss.     

Influence of cardiac circulation and medication on the perfusion of the intestine

Perfusion of the abdomen is determined by cardiac function and circulation. Intestinal ischemia can be caused by Non occlusive bowel ischemia (NOD) that is important in internal as well as surgical intensive care medicine. Cardiac medication can influence perfusion of the bowel: 1) digitalis increases muscular tonus and decreases perfusion regulation b) diuretics lead to hypovolemia, hypotonia and malperfusion, c) antihypertensive medication can cause intraoperative hypotension that demands catecholamines, d) catecholamines can reduce perfusion by pathologic vasoconstriction in the splanchnicus area. Preoperative medication should respect 1) preoperatively taken ACE-inhibitors should be given postoperatively, as they have protective influence on the microcirculation of the bowel, 2) beta-blockers stabilize the myogenic tonus of the abdominal vessels, reduce an overshot of the parasympatheticus and diminish the risk of neurogenic abdominal shock, 3) catecholamines should be used with respect to ischemia of the bowel. Therapy of NOD should be focused on the primary vascular and hemodynamic causes and also take care for bacterial translocation and consecutive sepsis.     

Gastric tonometry accurately predicts mortality in experimental peritonitis in both laparoscopic and conventional surgery

OBJECTIVES: Tonometry is widely used in the diagnosis of sepsis and splanchnic ischemia. This study was devised to analyze the predictive value of gastric tonometry for outcome of experimental viscus perforation-induced peritonitis. The impact of conventional and laparoscopic intervention on tonometric measurements was the main scope. METHODS: This randomized controlled intervention trial was performed in a University experimental laboratory, using 24 female Duroc pigs. Pigs were subjected to gastric perforation followed by a 12 h interval of peritonitis, and then to either laparoscopic or conventional surgical repair of the defect with peritoneal lavage. Gastric tonometry and cardiocirculatory monitoring were performed. RESULTS: Septic shock associated with peritonitis and subsequent lethal outcome was accurately predicted with gastric tonometry. Changes of gastric mucosal pH correlated significantly with decreases of MAP (r2=0.880; P<0.001) and SVR (r2=0.678; P<0.001), increase of QT (r2=0.486; P=0.013), and mortality (r=0.752; P<0.001). Mortality was significantly higher in laparoscopically treated animals compared to those subjected to the open procedure (78% vs 22%; P<0.045). CONCLUSIONS: Gastric tonometry accurately predicted mortality in experimental peritonitis. The decline of gastric mucosal pH in the laparoscopic group was more than double that of to conventionally treated animals. This finding not only reflected the increase of systemic CO2 due to higher absorption during CO2-pneumoperitoneum, but probably also indicated a more severe form of splanchnic ischemia during laparoscopic surgery. Even though tonometry can be used to accurately predict mortality and separate the high risk group, extreme caution should be applied under conditions associated with severe peritonitis.