Acute aortic occlusion secondary to aspergillus endocarditis in an intravenous drug abuser

A 55-year-old black man, an intravenous substance abuser who had an acute arterial embolus to the distal aorta originating from his mitral valve, was noted on pathologic examination of the clot to have aspergillosis emboli. The infective endocarditis also resulted in emboli to the brain with subsequent death.     

Botulism in a pregnant intravenous drug abuser

A case of botulism is reported in a heroin-abusing parturient who initially presented with lethargy and slurred speech. The diagnostic difficulty, complications, intensive care and anaesthetic management of this case are discussed, with particular reference to the pregnancy and the effects of both botulism and its empirical treatment on the fetus. A short review is provided of a condition that has seen a marked increase in its incidence since 2000.     

Primary reconstruction to avoid wound breakdown following groin block dissection.

We report our experience of immediate reconstruction of the groin using the deep inferior epigastric artery (DIEA) myocutaneous flap following 32 consecutive ilioinguinal block dissections for groin metastases in patients with penile carcinoma. All groin wounds healed primarily, resulting in a short postoperative hospital stay. Transferring one or both DIEA flaps did not lead to any significant functional disability.     

Spontaneous kyphotic collapse followed by autostabilisation secondary to cervical osteomyelitis in an intravenous drug abuser

There is a high risk of cervical osteomyelitis in intravenous drug abusers due to the use of jugular veins for administration of drugs. Here described is a case of rapid vertebral body destruction at two levels leading to a progressive kyphotic deformity followed by autofusion, secondary to cervical osteomyelitis. The case report goes on to hypothesise about the unique manner of progression of untreated cervical osteomyelitis with a rapid onset of kyphotic deformity and associated severe bone destruction in an intravenous drug abuser. Due to the high incidence of osteomyelitis in intravenous drug abusers, there should be a low threshold to investigate for this condition and early magnetic resonance imaging is vital. It alerts the treating spine surgeon to the fact that early immobilisation is crucial in these cases to prevent a severe impending deformity that can be surgically challenging.     

Endovascular management of an arteriovenous fistula and concomitant pseudoaneurysm in an intravenous drug abuser

An interesting case of an intravenous drug abuser who had endovascular management of an arteriovenous fistula and concomitant pseudoaneurysm, resulting from recurrent puncture of the femoral artery is reported in this study.     

Salmonella typhi splenic abscess in an intravenous drug abuser following splenorrhaphy: case report.

A recent case of posttraumatic splenic abscess in an HIV-positive intravenous drug abuser following a splenic salvage procedure is reported. With the recent trend toward splenic preservation and the ever-increasing population of HIV-positive, immune-compromised patients, the complication of splenic abscess may become more common.     

Postherniorrhaphy groin pain and how to avoid it

Groin pain following inguinal hernia repair remains a challenge to most general surgeons. Prevention of groin pain may be the most effective solution to this management problem and necessitates careful anatomic dissection and precise knowledge of surgical anatomy of the groin as well as potential pitfalls of surgical intervention. When complications arise, a period of watchful waiting is warranted, but surgical intervention with triple neurectomy offers the most definitive resolution of symptoms. This article aims to provide a thorough review of pertinent anatomic landmarks for the proper identification of the nerves that, if injured, result in chronic groin pain and to provide a treatment algorithm for patients suffering with this morbidity.     

Internal iliac artery revascularization as an adjunct to endovascular repair of aortoiliac aneurysms.

PURPOSE: Endovascular repair of aortoiliac aneurysms may be limited by extension of the aneurysm to the iliac bifurcation, necessitating endpoint implantation in the external iliac artery. In such cases the circulation to the internal iliac artery is interrupted. Bilateral internal iliac artery occlusion during endovascular repair may be associated with significant morbidity, including gluteal claudication, erectile dysfunction, and ischemia of the sigmoid colon and perineum. We have employed internal iliac artery revascularization (IIR) to allow endograft implantation in the external iliac artery while preserving flow to the internal iliac artery in patients with aneurysms involving the iliac bifurcation bilaterally. METHODS: A total of 11 IIR procedures were performed in 10 patients undergoing endovascular abdominal aortic aneurysm (AAA) repair (9 men, 1 woman; mean age, 74 years). IIR was accomplished via a retroinguinal incision in 9 cases and a retroperitoneal incision in 2 cases. Six-mm polyester grafts were used for external-to-internal iliac artery bypass in 10 cases and internal iliac artery transposition onto the external iliac artery was used in one case. Endovascular AAA repair was performed using a modular bifurcated device (Talent-LPS, Medtronics, Minneapolis, Minn) after IIR. Bypass graft patency was determined immediately after the surgery, at 1 month, and every 3 months thereafter, using duplex ultrasound scanning and computed-tomography angiography. Mean aneurysm diameters were as follows: AAA, 6.4 +/- 0.7 cm; ipsilateral common iliac, 3.7 +/- 1.0 cm; contralateral common iliac, 3.9 +/- 0.8 cm. RESULTS: Successful IIR and endovascular AAA repair were accomplished in all cases. No proximal, distal, or graft junction endoleaks occurred. Two patients demonstrated retrograde aneurysm side-branch endoleaks originating from the lumbar arteries. One thrombosed spontaneously within 3 months. One perioperative myocardial infarction occurred. Reduction in aneurysm size was documented in 5 aortic, 5 ipsilateral iliac, and 3 contralateral iliac aneurysms. Gluteal claudication, erectile dysfunction, colon and perineal ischemia, and mortality did not occur. All IIRs have remained patent during a follow-up period of 4 to 15 months (mean, 10.1 months). CONCLUSIONS: IIR may be used with good short-term to intermediate-term patency to prevent pelvic ischemia in patients whose aneurysm anatomy requires extension of the endograft into the external iliac artery. This may allow endovascular AAA repair to be performed in patients who might otherwise be at risk for developing complications associated with bilateral internal iliac artery occlusion.     

Descending thoracic aortofemoral bypass as an alternative for aortoiliac revascularization.

We performed descending thoracic aorta to femoral bypass in six selected patients over the past four years. An alternative inflow source was selected because the standard transabdominal approach was contraindicated or considered hazardous. The inflow consisted of a single Dacron tube from the descending thoracic aorta to the left groin, and a femorofemoral bypass to the right groin. There was no operative mortality or major morbidity related to the surgical procedure. After an average follow-up of 17.1 months (range 6 to 23 months), all thoracofemoral grafts remained patent. One patient had repeated occlusions of the femorofemoral graft related to right lower extremity outflow disease, while the remaining five crossover grafts are patent. One patient died 22 months postoperatively from a myocardial infarct, with a patent bypass. Although this series represents a small group of patients, we feel that descending thoracic aortofemoral bypass offers excellent inflow and reliable patency, and is a good alternative when reoperation on the abdominal aorta is undesirable. This procedure may also be considered for conversion of an axillofemoral bypass that has failed repeatedly.     

Descending thoracic aorta-to-iliofemoral artery bypass as an alternative to aortoiliac reconstruction.

During the last 3 decades subcutaneous extraanatomic bypass, despite its limited durability, has been the favored alternative to infrarenal aortofemoral bypass. Meanwhile, the descending thoracic aorta has been scarcely used as an inflow source for aortoiliac reconstruction. Over the past 8 years we performed 16 bypasses from the descending thoracic aorta to the iliofemoral vessels for occlusive disease. Our experience combined with that found in the English-language literature totaled 141 patients. In 79 patients (56%) the indication for surgery was failure or infection of an abdominal aortofemoral graft. Previous abdominal operations, sepsis, radiation therapy, the presence of abdominal stomas, or an unsuitable infrarenal aorta were the indications in the remaining cases. The combined operative mortality rate was 6.4%. The life-table primary graft patency was 98% at 1 year, 88% at 2 years, and 70.4% at 5 years. Bypass from the descending thoracic aorta to the iliofemoral artery uses an inflow source superior to other extraanatomic reconstructions, does not require aortic cross-clamping, avoids the abdominal cavity, and places the graft remote to the skin and intestine. The operative mortality and patency rates compare favorably to those of other extraanatomic or remedial aortic reconstructions. Descending thoracic aorta to iliofemoral artery bypass is a superb alternative to abdominal aortofemoral bypass, carries a low mortality rate, has an excellent short-term patency, and features unique characteristics for long-term durability.     

Thoracoepigastric flap for the closure of an elbow defect in an intravenous drug abuser: A case report and review of literature

The reconstruction of large soft tissue defects of the upper extremity is a challenging problem. Although free tissue transfer in a single stage is preferred, the recipient blood vessels usually determine the outcome. Due to venous occlusion from repeated intravenous drug abuse, the use of a thoracoepigastric flap to cover a complex wound of the elbow is reported.     

Are there practical alternatives to aortoiliac reconstruction?

Experience with axillofemoral and femorofemoral grafting has indicated that both procedures can be performed in elderly poor risk patients with disabling aortoiliac occlusive disease with low operative mortality and minimal morbidity. In our experience the one year success rate of axillofemoral grafts is 80 per cent and the one year success rate of femorofemoral grafts is greater than 90 per cent. There have been no late failures of femorofemoral grafts in this series, although several axillofemoral grafts have failed between one and six years postoperatively. On the basis of these results, we believe that axillofemoral grafts should be reserved for elderly, poor risk patients in danger of loss of limb from aortoiliac occlusive disease. On the other hand, we consider femorofemoral grafting to be the procedure of choice for patients with symptomatic occlusive disease of one iliac arterial system when a femoral pulse of good quality exists in the opposite groin.     

Radiated groin wounds: pitfalls in reconstruction

Reconstruction procedures of soft tissue defects created after tumor excision in the ilioinguinal region which have received prior radiation therapy are associated with serious morbidities. Despite the availability of muscle or myocutaneous flaps, wound infection, wound breakdown, and necrosis occur with relative frequency. Changes in tissues secondary to radiation therapy are chronic and permanent and adversely affect wound healing. Tumors in this region should be considered for primary excision and reconstruction, followed by radiation, if necessary.     

杂交技术在冠状动脉外科中的应用

目的总结29例杂交技术治疗冠心病的临床疗效。方法2000年1月~2005年4月,29例冠心病接受杂交技术进行心肌血管化。均为男性,年龄(62.8±9.7)岁。其中合并高血压23例,糖尿病5例,慢性阻塞性肺病2例,陈旧性心肌梗死14例。二支病变10例,三支病变19例。左室射血分数0.576±0.108。结果29例接受33根移植物,其中左乳内动脉(left internalm amm ary artery,LIMA)27支,大隐静脉6支。共植入支架41个。平均每例心肌血管化2.5支。全组无死亡,无住院并发症。LIMA血流量(45±14)m l/m in。胸腔引流量(274±197)m l,2例(6.9%)接受输血。ICU时间(1.9±0.1)d。术后住院4~11 d,平均7.5 d。29例随访0.5~5.1年,(2.2±0.9)年,无远期死亡和心肌梗死。术后心功能NYHA分级Ⅰ级25例,Ⅱ级4例。冠脉造影共4例,大隐静脉桥血管闭塞1例,支架内再狭窄2例。结论杂交技术治疗冠心病中期疗效满意,适用于高危病人,其长期效果有待进一步评价。     

Carpal osteomyelitis in an intravenous drug user

The authors reported one case of carpal osteomyelitis in a female drug user. Treatment entailed intravenous antibiotics and early physiotherapy. Carpal osteomyelitis is uncommon, but intravenous drug users are mainly affected.     

Failure to culture bacteria in groin lymph nodes during arterial reconstruction

A prospective trial was undertaken to establish if infection of groin lymph nodes was a significant risk factor in postoperative wound infection in patients undergoing groin dissection for arterial reconstruction surgery. In a series of 32 patients there was no growth on culture of any lymph nodes biopsied. None of the cases developed a post-operative infection discharging pus. In five cases minor superficial infections occurred from which bacteria were cultured. All resolved rapidly. All patients received prophylactic systemic antibiotics. We conclude that our present direct approach via a short vertical incision carries no increased risk of infection and has the advantage of speed and simplicity. It is unnecessary to make any special more complicated incision designed to avoid lymphatics.