Vascular compromise after insertion of a retrograde femoral nail: case report and review of the literature

The authors describe entrapment of the popliteal artery within fragments of an open supracondylar femur fracture after reduction and stabilization with a retrograde femoral nail. At the time of fracture fixation, the loss of pedal pulses was noted, and an exploration of the popliteal vessels was performed. The popliteal artery was easily identified and dissected free after extension of the patient's lateral thigh wound. Following thrombectomy, blood flow to the distal extremity was restored and no postoperative vascular sequelae were encountered.     

Limb ischemia associated with persistent sciatic artery aneurysms-a report of 2 cases

Persistent sciatic artery (PSA) is a rare developmental anomaly, usually associated with iliofemoral hypoplasia and dependence on the sciatic artery as the dominant inflow to the lower extremity. Although rare, this anomaly is associated with a very high rate of aneurysm formation and frequent thromboembolic complications presenting as lower extremity ischemia, and requires familiarity on the part of the vascular surgeon to properly diagnose the disorder and plan therapy. The authors present 2 cases of PSA presenting with lower extremity ischemia and review the pathophysiology, diagnosis, and treatment of this rare but important anomaly.     

Occult intraspinal anomalies and congenital scoliosis

Of 251 patients with congenital scoliosis, occult congenital intraspinal anomalies were diagnosed in forty-six (18.3 per cent). A diastematomyelia was the commonest anomaly (forty-one patients). Other less common anomalies, occurring alone or in association with a diastematomyelia, were: neurenteric, epidermoid, and dermoid cysts; teratoma; lipofibroma; absence of nerve roots; fibrous bands; and a tight filum terminale. Intraspinal anomalies were associated with all types and sites of congenital scoliosis by far the highest incidence (52 per cent) occurred in association with a unilateral unsegmented bar with contralateral hemivertebrae in the lower thoracic or thoracolumbar regions. Thirty of the patients with an intraspinal anomaly had neural abnormalities, which usually affected only one lower extremity, and in twenty-four patients a paralytic foot deformity developed. Neural deterioration occurred in nine of these patients before the age of five years and was halted by excision of the anomaly. An additional twelve patients (4.8 per cent) of the 251 with congenital scoliosis also had a unilateral neural deficit in the lower limb and a paralytic foot deformity, similar to those found in the patients with an intraspinal anomaly, but had no myelographic evidence of a structural anomaly.     

Concurrent thrombosed aneurysmal sciatic artery and anomalous aortic arch

A persistent sciatic artery is a rare developmental anomaly which may predispose to a range of vascular complications. We report a 60-year-old woman presenting with right lower limb ischemia. Computed tomography angiography revealed an aneurysmal right-sided sciatic artery occluded by thrombus. An aberrant right subclavian artery and anomalous common carotid origins were also incidentally discovered. It is unknown whether an association exists between a persistent sciatic artery and other congenital arterial abnormalities. This is the first case report, so far as we are aware, describing both such arterial anomalies coexisting in a patient.     

Manifestation of popliteal aneurysm during pulse spray thrombolysis (PST)

We report the case of a 32-year-old woman presenting with acute extremity ischemia due to thrombosis of a previously undetected popliteal artery aneurysm. The popliteal artery aneurysm was revealed by PST which was indicated for the treatment of thrombosis of the superficial femoral artery. PST was complicated by a peripheral embolism with subsequent severe extremity ischaemia. Immediate embolectomy and reconstructive vascular surgery led to a successful result. This case illustrates the diagnostic problems of a thrombosed popliteal artery aneurysm and warns of embolic complications during PST.     

Agenesis of gall bladder in laparoscopic cholecystectomy—A case report

IntroductionAgenesis of gallbladder is a rare congenital anomaly of biliary tree that may be associated with other biliary and extra biliary congenital anomalies.Case presentationA 43- year- old female presented with a 4 months history of upper abdominal pain associated with nausea and vomiting. It was associated with dyspeptic symptoms and become worse following ingestion of high-fat meal contents. Clinically, a differential of gall stone disease was considered. Ultrasonography of abdomen revealed a contracted gallbladder with multiple stones with normal wall thickness, so the fact of clinical diagnosis considering finding cholithiasis. She was submitted to laparoscopic exploration which revealed that the gall bladder was absent within gall bladder fossa.DiscussionIn this case, the differential of cholithiasis symptoms considered support by ultrasonography, symptomatic gall stones presented more than half of cases of gall bladder agenesis, Diagnosis of gall bladder disease usually done by ultrasound modality, it must be done by expert one. Awareness of this entity by clinicians, surgeons and radiologists are essential because many of these patients present with biliary symptoms and have unnecessary operations.ConclusionAgenesis of gallbladder should be kept in mind whenever the gall bladder was improperly visualized in routine imaging methods. Ultrasonography operated dependent we must not depend on single one or even multiple done by the same person. Avoid a needless surgical exploration, which might be risky. Non-visualized gall bladder during laparoscopic cholecystectomy is challenging should not convert to open unless sure that the gall bladder was present.     

Popliteal artery entrapment syndrome

The popliteal artery entrapment syndrome is characterized by extrinsic compression of this artery as a result of anatomic deviation from its usual course, or by compression from musculotendinous structures in the popliteal fossa. Clinical symptoms appear when these affected individuals do strenuous exercises. There are two types of popliteal artery entrapment syndrome: the classicalor congenital form, and the functional or acquired form. In the classical form, disturbances in the embryogenesis lead either directy to popliteal artery anomalies or to alterations of adjacent structures that cause compression of the popliteal artery. In the functional form, hypertrophy of the gastrocnemius muscle secondary to exercise has been postulated as a cause. In both types, diagnosis is made through the detection of total occlusion or important stenosis of the popliteal artery. This is identified by duplex scan, magnetic resonance or arteriography during active plantar flexion-extension. A positive test in non-symptomatic subjects presenting no anatomical anomalies led to discussions about its specificity. This study presents a review of anatomical and functional popliteal artery entrapment syndrome and discusses accuracy, sensitivity and specificity of the diagnostic tests.     

Acute shortening and lengthening following vascular repair with a vein graft for Gustilo–Anderson type IIIC open fracture: A report of two cases

We present two cases of lower extremity open fractures with vascular injury, where acute shortening and early lengthening were performed, following vascular repair with a vein graft. The two patients sustained Gustilo–Anderson type IIIC open fractures (one patient in the tibia and the other patient in the femur) with disruption of the popliteal artery. Initially, they were treated with debridement and stabilization using an external fixator. The disruptions of the popliteal artery were repaired by interposition of a saphenous vein graft. As soon as possible after the injury, the bone segment was resected and shortening was initiated with careful monitoring of blood circulation. After the bone gap and soft-tissue defects were closed at the end of the shortening, distraction osteogenesis was carried out in the proximal part of the tibia and the femur, respectively.There is not study reporting acute shortening and early lengthening performed on patients who underwent vascular repair with a vein graft. The procedures did not affect blood circulation, and resulted in a good clinical outcome. We consider this method a safe and effective way to treat lower extremity open fractures with vascular injury and massive soft tissue defects.     

Popliteal artery entrapment syndrome

Popliteal Artery Entrapment Syndrome (PAES) is an uncommon congenital anomaly. It arises due to compression of the popliteal artery by tendomuscular structures often combined with an anomalous position of the artery. Mostly young men are suffering of this disease. There are four common variations of this anomaly. We report on a 14 year old patient who had an acute 24 hours duration right leg ischemia caused by PAES. Using a posterior approach to the popliteal artery, following division of the accessory slip of gastrocnemius muscle we performed an arteriotomy and a floating thrombus was removed. The artery was reconstructed by direct continuous suture. One year postoperatively the boy has no complaints, peripheral pulse is palpable.     

A PULSATILE GLUTEAL MASS DUE TO SCIATIC ARTERY ANEURYSM

A persistent sciatic artery is a rare congenital anomaly where the internal iliac artery and the original axial artery of the embry continue to provide the major blood supply to the lower limb after birth. Its predisposition to atherosclerosis, aneurysmal degeneration of its gluteal segment and association with other congenital anomalies are important for its management. W report a patient who highlights these aspects and we provide a brief review of this unusual condition.     

Persistent sciatic artery aneurysm: a case report

In early embryologic development the sciatic artery provides the blood supply to the lower limb bud. When the femoral artery develops, the sciatic artery involutes. However, in rare cases, the sciatic artery persists. It can be visualised as a prolongation of the inferior gluteal artery (branch of the internal iliac artery) and it accompanies the sciatic nerve at the posterior side of the hip. We present the case of a 47-year old woman who consulted because of a numb right foot which presented colder and paler than the left foot. She also had a right painful calf, especially after exercise. Upon physical examination and doppler ultrasound there were no popliteal nor pedal artery pulses in the right leg. CT angiography showed bilateral persistent sciatic arteries with aneurysm formation and the presence of an embolus in the popliteal artery at the right side. Treatment involved thrombolysis of the popliteal occlusion, followed by intra-aneurysmatic stent placement and embolectomy of the popliteal artery and its distal branches. Postoperative clinical results were remarkably good and the patients symptoms dissolved. CONCLUSION: A persistent sciatic artery is a rare vascular anomaly. It is more prone to vasculopathies such as aneurysm formation. In cases of acute ischemia, correct diagnosis and treatment of this anomaly can avoid serious medical consequences.     

56例腘动脉以下肢体动脉缺血的血管重建术分析

目的总结腘动脉水平动脉闭塞血运重建术治疗的临床疗效。方法对2001年7月至2005年8月56例累及腘动脉及腘动脉以下三分支病变重建肢体血运进行回顾性分析。根据病变阻塞平面不同,采用不同的血管架桥,对多平面、多节段动脉闭塞采用聚四氟乙烯人工血管和自体静脉桥复合序贯架桥血运重建。结果术后平均随访17个月,移植血管一期通畅率67．3％,二期通畅率78．8％。结论复合序贯搭桥术治疗累及股浅-腘动脉水平以下多节段（平面）动脉闭塞症是一种较实用的方法,可有效解决自体血管不足和单纯使用人工血管腘动脉以下血管重建通畅率差的问题。     

Congenital anomalies of the external iliac artery: case report and review of the literature

Routine arteriograms obtained during work-up for occlusive arterial disease of the lower limbs disclosed a rare congenital anomaly in a 47-year-old man. The common femoral artery arose directly from a pelvic artery which followed the normal course of the internal iliac artery. Congenital anomalies involving the external iliac artery can be classified into three groups: (1) anomalies of origin or course which are in fact anatomic curiosities; (2) hypoplasia or atresia coexisting with persistent sciatic artery; and, (3) isolated hypoplasia or atresia which can occasionally cause chronic ischemia of the lower limbs. The anomaly reported herein can be classified either as agenesia or abnormal course of the external iliac artery.     

Common Origins of Carotid and Subclavian Arterial Systems: Report of a Rare Aortic Arch Variant

An aberrant right subclavian artery (aSA) arising from the proximal descending aorta is one of the most common anomalies of the aortic arch. We present our experience with an asymptomatic atypical aSA variant found during routine anatomic dissection. This aortic arch variant had two branches, the first being a bicarotid trunk and the second being a common trunk for both subclavian arteries. The right subclavian artery traveled behind the esophagus to reach the right upper extremity, thus forming an incomplete vascular ring around the trachea and the esophagus. The literature has been silent about the existence of this exact aSA variation. A plausible embryologic explanation is provided. An aSA is rarely symptomatic, but when symptoms do occur and intervention is warranted, it is important for surgeons and radiologists alike to be aware of the vascular anomalies that may potentially coexist with this entity. The surgical and endovascular options associated with this unique vascular anomaly are also discussed.     

腘动脉压迫综合征八例

目的 总结腘动脉压迫综合征诊治经验.方法 回顾性分析2002年7月至2010年7月收治的8例患者临床资料,其中男性7例,女性1例,年龄16～56岁,平均(29±14)岁.6例经腘窝S形切口发现并解除解剖畸形,2例腘动脉局限性狭窄合并远侧腘动脉瘤,其中1例行腘动脉缩缝成形,1例切除部分动脉瘤壁以自体大隐静脉补片成形;4例患者腘动脉闭塞,其中2例行腘动脉血栓内膜剥脱术(1例自体大隐静脉补片成形术),1例行自体大隐静脉间置术,1例行自体大隐静脉旁路手术.2例腘动脉闭塞病变较长者直接经膝下内侧切口行自体大隐静脉旁路手术.结果 8例患者术后恢复良好出院,随访4～99个月,平均(50±37)个月.7例患肢血运良好,正常活动.1例自体大隐静脉旁路术后51个月远端吻合口及腘动脉分支狭窄,行球囊扩张术后1个月后再闭塞,经保守治疗后轻度跛行.结论 腘动脉压迫综合征是导致青少年下肢缺血的少见疾病,早期正确诊断和及时手术治疗可取得良好效果.

Abstract：

Objective To summarize our experience on the diagnosis and management of 8 patients with popliteal artery entrapment syndrome (PAES). Methods Clinical data of 8 PAES cases admitted from Jul 2002 to Jul 2010 were retrospectively analyzed. There were 7 males and 1 female with the mean age of (29 ± 14)years (ranging 16 -56 years). In 6 cases posterior "S" shaped incisions in the popliteal fossa were applied and anomalous anatomic structures were verified. Segmental stenosis and post-stenotic popliteal arterial aneurysm was identified in 2 cases, and partial resection of the aneurismal wall and arterioplasty including one with saphenous vein patch were applied; For 4 cases with short segmental occlusion of the popliteal artery, surgical treatment included thromboendarterectomy in 2 cases (with saphenous vein patch plasty in one case), saphenous vein interposition in 1 case, and saphenous vein bypass grafting in 1 case.Medial longitudinal incisions and saphenous vein bypass grafting were applied in 2 cases with long segmental occlusion in popliteal artery without exploration for anatomic anomalies. Results All patients recovered uneventfully without any notable complication. During the follow-up period ranging from 4 to 99 months [average (50± 37) months], no ischemic symptom reoccurred in 7 cases with patent arteries or grafts, and recurrent claudication occurred in 1 case with distal anastomostic stenosis. The stenosis was subsequently treated with balloon angioplasty and vein graft thrombsis occurred one month later. Medicine and exercise were recommended for the patient and now mild claudication still remains without affecting his normal life.Conclusions PAES is a disease of relatively low incidence resulting in lower extremity ischemia, which can be successfully cured with proper management.     

Coil embolization of symptomatic persistent sciatic artery aneurysm: a case report

Persistent sciatic artery is a rare congenital vascular anomaly of the lower extremity. This artery is predisposed to atherosclerosis or aneurysm formation. Persistent sciatic artery aneurysm often causes limb-threatening ischemia owing to its thrombosis or its mural thrombus. We report a case of successful transcatheter coil embolization for persistent sciatic artery aneurysm. An 89-year-old woman presented to our hospital, suffering from severe ischemia of the right leg and a pulsatile mass in the right buttock. Angiography and enhanced computed tomography revealed right persistent sciatic artery aneurysm with mural thrombus and complete occlusion of the distal end. After she underwent major amputation because of the advanced ischemia following unsuccessful thrombectomy, we performed coil embolization for the aneurysm successfully. Endovascular treatment including transcatheter embolization for persistent sciatic artery aneurysm is safe, effective, and less invasive than surgery. Its application gives various therapeutic options for the treatment of persistent sciatic artery aneurysm.     

Popliteal artery injuries in an urban trauma center with a rural catchment area: do delays in definitive treatment affect amputation?

Extended length of time from injury to definitive vascular repair is considered to be a predictor of amputation in patients with popliteal artery injuries. In an urban trauma center with a rural catchment area, logistical issues frequently result in treatment delays, which may affect limb salvage after vascular trauma. We examined how known risk factors for amputation after popliteal trauma are affected in a more rural environment, where patients often experience delays in definitive surgical treatment. All adult patients admitted to the Level I trauma center, the University of Mississippi Medical Center, with a popliteal artery injury between January 2000 and December of 2007 were identified. Demographic information management and outcome data were collected. Body mass index, mangled extremity severity score (MESS), Guistilo open fracture score, injury severity score, and time from injury to vascular repair were examined. Fifty-one patients with popliteal artery injuries (53% blunt and 47% penetrating) were identified, all undergoing operative repair. There were nine amputations (17.6%) and one death. Patients requiring amputation had a higher MESS, 7.8 versus 5.3 (P < 0.01), and length of stay, 43 versus 15 days (P < 0.01), compared with those with successful limb salvage. Body mass index, injury severity score, Guistilo open fracture score, or time from injury to repair were not different between the two groups. Patients with a blunt mechanism of injury had a slightly higher amputation rate compared with those with penetrating trauma, 25.9 per cent versus 8.3 per cent (P = non significant). MESS, though not perfect, is the best predictor of amputation in patients with popliteal artery injuries. Morbid obesity is not a significant predictor for amputation in patients with popliteal artery injuries. Time from injury to repair of greater than 6 hours was not predictive of amputation. This study further demonstrates that a single scoring system should be used with caution when determining the need for lower extremity amputation.     

In situ femoral to popliteal bypass graft using superficial femoral vein to popliteal vein

During the evolution of vascular surgery as a specialty, many conduits have been used to revascularize the lower extremities. Superficial veins and prosthetic materials make up the majority of materials used to bypass diseased segments of native artery. The deep veins of the thigh have also been reported as alternatives for arterial bypass. However, the use of the in situ superficial femoral and popliteal vein bypass has not been reported to our knowledge in current literature. We report a 79-year-old white female with lower extremity rest pain who underwent an in situ femoral popliteal bypass graft for limb salvage.     

Treatment of the persistent sciatic artery.

The persistent sciatic artery is a rare vascular anomaly, with only 37 reported cases in the world literature. Estimates of incidence, based on angiographic series, range from 0.04 to 0.06%. It may pose a threat to the viability of the lower extremity, for the pathologic character of the persistent sciatic artery is such that it is especially prone to atheromatous degeneration, thrombosis, distal thromboembolization, aneurysmal formation, and rupture. Although rare, the possibility of such an anomaly must be borne in mind with certain clinical presentations, during orthopedic procedures on the hip, and during angiographic studies of the leg. Successful surgical correction of the problem necessitates excluding the anomalous artery from the circulation while revascularizing the lower extremity.     

Bartsocas-Papas syndrome: The first case report of severe autosomal recessive form from Indonesia

IntroductionBartsocas-Papas syndrome (BPS) is an autosomal recessive form of Popliteal Pterygium syndrome (PPS). It is a very rare disease characterized by congenital craniofacial anomalies, popliteal webbing, and genitourinary and musculoskeletal anomalies. Almost all of the cases were reported in dead intrauterine pregnancies.Presentation of caseWe present a 10-month-old boy with bilateral complete cleft lip and palate, abnormal scalp hair, an absence of both upper eyelids, choanal atresia, syndactyly of the third and fourth fingers of the right hand, agenesis fingers on the left hand, bilateral popliteal pterygia, bilateral talipes equinovarus, agenesis of the toes of both lower extremities, intercrural webbing, an absence of testis, and scrotal anomaly. Multistage surgical correction was performed for the multiple congenital malformations.ConclusionWe report the first case of BPS from Indonesia. Gradual management should be performed according to the patient's age and available facilities.