The jugular vein as an interposition graft in the distal splenorenal shunt

The selective distal splenorenal shunt is the preferred portal decompression procedure for patients with refractory bleeding esophageal varices. An autogenous jugular vein interposition graft in the distal splenorenal position obviates the tedious struggle associated with mobilizing the splenic vein from the pancreatic substance, thereby lessening blood loss, avoiding postoperative pancreatitis and shortening operative time. An autogenous jugular vein interposition distal splenorenal shunt can, therefore, be performed with less morbidity while affording the same physiologic benefits as the standard distal splenorenal shunt.     

Left sided segmental portal hypertension following mesocaval interposition shunt.

Following a mesocaval interposition shunt in three patients with cirrhosis of the liver, bleeding esophageal varices recurred in two and left sided portal hypertension partially persisted in one patient. Angiographic and pressure studies of the portal system demonstrated effective decompression of the greater splanchnic venous system but continued lesser splanchnic venous hypertension. Recurrent variceal hemorrhage ceased following splenectomy done as an emergency. In contrast to a standard portacaval shunt, it is suggested that after an interposition mesocaval shunt, altered jet streaming of mesenteric blood flow may divert gastrosplenic venous drainage away from the interposition shunt with persistence of lesser splanchnic venous hypertension. Recognition of this entity and of the need for splenectomy is advocated.     

Manifestations of carcinoma of the uncinate process by means of superior mesenteric arteriography

Identification of carcinoma arising in the uncinate region of the pancreas is difficult because of the peculiar topographic relationship of this lesion with adjacent structures. Among the various diagnostic procedures performed upon ten patients with this malignant lesion, superior mesenteric arteriography provided the most helpful information, including signs of invasion in the main trunk of the superior mesenteric artery and vein and in the proximal portion of the jejunal arteries. A clearer visualization of these vascular involvements was attained in the right posterior oblique projection rather than in the anteroposterior projection. On the contrary, the arterial and portal vessels belonging to the celiac territory, such as superior pancreaticoduodenal arteries, dorsal pancreatic artery, gastroduodenal artery, splenic vein and portal vein, were almost free of involvement. At laparotomy, almost all of the patients had direct extension of the tumor to the superior mesenteric vessels, forming a cancerous core in the root of mesentery. All died of cachexia within six months after a palliative surgical procedure. Serial roentgenograms of superior mesenteric artery, especially taken in the oblique projection, are the best means of confirming carcinoma of the uncinate process, for which only a few available methods have been established to evaluate the clinical aspects.     

Internal jugular venous autograft in extrahepatic portal hypertension.

A 26 year old female with repeated episodes of upper gastrointestinal bleeding, secondary to extensive extrahepatic portal and superior mesenteric venous obstruction, was surgically treated by interposing an internal jugular vein autograft between a collateral channel and the inferior vena cava. The follow-up observation during a seven and one-half year period has shown no recurrence of bleeding, disappearance of esophageal varices and a widely patent graft with normal portal vascular pressures. The internal jugular vein is a readily accessible autogenous graft of adequate caliber that can maintain patency under rigorous conditions. Its use is recommended in constructing portal-systemic venous shunts in those instances of extrahepatic portal hypertension in which conventional shunts cannot be established or, if they can be established, are liable to closure.     

Portosystemic shunts for extrahepatic portal hypertension in children

Twenty-three children with prehepatic portal hypertension and hemorrhage due to ruptured esophagogastric varices had portosystemic shunts. Their ages ranged from two years and seven months to 15 years. Eleven were less than eight years of age. Twenty patients had portal vein cavernomatosis and three patients had double portal veins. In 21 patients, a mesocaval type of shunt was done. A splenorenal shunt was performed in two. There was no surgical mortality. Two shunts occluded, both in rather young infants--two years and seven months and three years of age. In all the others, there was no further bleeding, and the shunts remained patent, as shown by abdominal angiograms. Neuropsychiatric disorders, probably due to hepatic encephalopathy, occurred in only one patient. On the basis of this favorable experience, we believe that an elective portosystemic shunt should, in general, be performed upon children with prehepatic portal hypertension after one major variceal hemorrhage. We favor a mesocaval type of shunt in these children because of the larger diameter of the vessels involved in the anastomosis and because it preserves the spleen, maintaining defense against subsequent infection.     

Management options for penetrating injuries to the great veins of the neck and superior mediastinum

Between January 1984 and January 1986, 74 patients were treated for stab or gunshot injury to the great veins in the neck and superior mediastinum. Veins involved in the neck were the subclavian and internal jugular and in the mediastinum, the brachiocephalic and subclavian vein and the superior vena cava. Most patients presented in a state of shock. Twenty-nine were bleeding too rapidly to resuscitate adequately and required emergency operation while in a moribund state. Twenty-five had arteriovenous fistulas and were hemodynamically stable. Direct venous repair was attempted if simple lateral suture or end to end anastomosis could be rapidly done. If complex repairs were required, ligation was performed. Fifty-five veins were ligated on this basis, including 14 brachiocephalic trunks, nine proximal subclavian veins and one superior vena cava cephalad to the azygos. Nineteen were repaired. Two patients died after ligation and one patient after repair, all as a result of the effects of massive hypovolemia. Edema of the upper limb developed in two patients in each treatment group in whom the distal part of the subclavian vein had been involved. The edema resolved within five to seven days. Chronic venous stasis problems did not develop in any patient during the two to 26 month follow-up period.     

The significance of elevated peritoneal fluid phosphate level in intestinal infarction

Early diagnosis seems mandatory if the mortality of mesenteric vascular occlusion is to be altered. A model has been developed in which intestinal infarction has been produced by ligation of either the superior mesenteric vein or the superior mesenteric artery. Results of earlier work, using this model, have shown a significant rise in the serum inorganic phosphate level and an associated severe metabolic acidosis. This article has confirmed these results as being statistically significant. In this experiment, a significant rise in the inorganic phosphate level of the peritoneal fluid has been shown in the same model. We suggest that, in the patient with possible intestinal infarction, an elevated serum phosphate level, elevated peritoneal fluid phosphate level, base deficit and leukocytosis may be useful in making an earlier diagnosis of this disease. If an earlier diagnosis is accomplished, the morbidity and mortality of this lethal disease hopefully will be reduced.     

Fetal superior mesenteric artery blood flow velocimetry in normal and high-risk pregnancy

THE AIM: To record blood flow velocimetry in the fetal superior mesenteric artery in normal pregnancy and to evaluate if blood flow recordings in the vessel might predict adverse outcome in high-risk pregnancy. METHODS: The fetal superior mesenteric artery blood velocimetry was recorded in a cross sectional manner in 75 normal pregnancies between 27 and 41 weeks of gestation. Reference curves were performed for pulsatility and resistance indices. The superior mesenteric artery was also located in 48 singleton pregnancies complicated by pregnancy-induced hypertension and/or intra-uterine growth retardation. Middle cerebral artery, umbilical artery and vein and uterine artery velocimetry were also recorded. RESULTS: Superior mesenteric artery PI and RI values expressed an increase in resistance to blood flow with gestational age after 32 weeks of gestation. In all except eight high-risk pregnancies the fetal mesenteric artery PI values were within normal range. Among the pregnancies with absent or reversed blood flow in the umbilical artery, all had abnormal mesenteric artery pulsatility index (PI) (> 97.5th percentiles), one fetus died intrauterine and two others died after delivery due to prematurity, growth retardation and necrotizing enterocolitis. In the remaining fetuses with increased mesenteric artery PI, necrotizing enterocolitis was diagnosed in three cases. CONCLUSIONS: Increased vascular resistance in the mesenteric artery might be a late sign of fetal circulation redistribution and frequently related to necrotizing enterocolitis in the newborn.     

The internal jugular vein thrombosis during pregnancy with decreased level of protein S

The study presents a rare case of internal jugular vein thrombosis during pregnancy. The patient's only complaints were headaches which increased after conception. In the 11th week of pregnancy thrombosis of the internal left jugular vein was diagnosed. Since then, patient had been treated with low molecular weight heparin. Further course pregnancy, delivery and puerperium were not complicated. The decreased level of protein S was responsible for the internal jugular vein thrombosis in this case.     

Right atrial catheter insertion through the external jugular vein.

The external jugular vein may be used to place a right atrial catheter if the cephalic veins are not suitable for cannulation. Atrophy or sclerosis of the cephalic vein is seen in some patients with malnutrition or a malignant lesion. Some women patients also have cephalic veins of rather small caliber. In these patients, the insertion of the right atrial catheter, using the external jugular vein, may be warranted. The external jugular vein approach is recommended because of its easy accessibility and the lower risk involved than with the internal jugular or cephalic vein approach.     

Interposition mesocaval shunt for chronic primary occlusion of the hepatic veins.

Five patients with primitive chronic Budd-Chiari syndrome were treated by Dacron interposed mesocaval shunts for medically uncontrollable ascites. In two instances, hepatomegaly and ascites disappeared for four and four and one-half years. In one patient with severe stenosis of the inferior vena cava, moderate ascites required tapping once a month one year later, despite proved prosthesis patency. In two patients, death occurred ten and 30 days after shunting due to thrombosis of the graft. Inferior vena cava stenosis appears to be the major factor for decision of opportunity and type of portacaval shunt. From our material, we can describe three types of stenosis: type I, due to caudate lobe hypertrophy, and type II, due to right lobe hypertrophy, are suitable for side-by-side portacaval or mesocaval shunts. Type III, regular and extended narrowing of inferior vena cava, observed in long term evolutive forms, is presumably due to fibrosis and is not a good indication for conventional infrahepatic shunting procedures. Since this study was completed, another patient had a side-to-side portacaval anastomosis for chronic Budd-Chiari syndrome without caval stenosis. The patient has been observed for seven months, and ascites did not reappear. This underlines the importance of a complete radiologic and hemodynamic preoperative study of inferior vena cava outflow impairment.     

Recurrent stenosis after carotid endarterectomy.

Thirteen of 1,250 patients required a second operation for recurrent stenosis following carotid endarterectomy performed at the Cleveland Clinic between 1958 and 1978. Two other patients underwent reoperation because of recurrent stenosis following primary operations at other institutions. Thirteen of the 15 patients experienced neurologic symptoms caused by recurent stenosis, while two patients remained asymptomatic. Atherosclerosis was responsible for recurrent stenosis in 12 patients and appeared to be related to hypercholesterolemia. Three of the patients had myointimal fibroplasia. Eleven of the 16 reoperations for recurrent stenosis of the carotid artery consisted of carotid endarterectomy with vein patch angioplasty. Three patients had carotid endarterectomy with closure of the primary arteriotomy. One patient with occlusion of the internal carotid artery underwent endarterectomy of the external carotid artery because of amaurosis fugax, and a saphenous vein interposition graft was used to replace a previous Dacron graft in one patient with anastomotic stenosis. One patient had a stroke during reoperation manifest as multiple retinal emboli. Fourteen patients have remained asymptomatic from one to 70 months following reoperation. One patient with occlusion of the contralateral internal carotid artery has experienced persistent vertebrobasilar symptoms.     

Angiographic evaluation of hepatoma for surgical treatment.

Celiac and superior mesenteric arteriography of 60 patients with primary carcinoma of the liver was evaluated retrospectively to select patients properly for hepatic lobectomy, ligation of the hepatic artery or temporary occlusion of the hepatic artery. The angiograms were studied from the viewpoints of origin of the hepatic artery, location of hepatomas, macroscopic type of hepatomas, tumor supplying arteries, patency of the portal vein and coexistence of cirrhosis of the liver. It is stressed that an exact knowledge of these items before operation is important in performing any type of surgical treatment for patients with hepatomas. Resectability of the tumor in the present series of patients was possible in 11 patients, and in the recently seen patients with nonresectable hepatomas, ligation or repeated temporary occlusion of the hepatic artery or both have been performed with postoperative infusion chemotherapy.     

Late-onset congestive heart failure with multiple carotid-jugular fistulae and pseudoaneurysm after penetration injury.

Trauma-acquired multiple arteriovenous fistulae with late-onset congestive heart failure has not been documented. We describe a 29-year-old man who presented with progressive congestive heart failure 25 years after a penetrating trauma to the left side of the neck. The neck duplex showed a large shunt between the carotid artery and internal jugular vein. Arteriography showed three high-flow arteriovenous fistulae between these two vessels. Magnetic resonance angiography (MRA) showed a carotid pseudoaneurysm originating from three different loci of the carotid artery with a large aneurysm-venous communication between the pseudoaneurysm and the internal jugular vein. Reconstruction of contrast MRA showed three different arteriovenous fistulae, leading to the decision to perform aneurysmectomy, carotid artery repair and jugular vein patch angioplasty. The favorable outcome of this case illustrates that surgery is a reasonable alternative when an endovascular approach is not feasible in patients with trauma-acquired arteriovenous fistulae.     

Percutaneous cannulation of the internal jugular vein in infants and children.

A technique for percutaneous catheterization of the internal jugular vein in infants and children was used since January 1975 in 206 patients ranging in age from a few hours to 12 years old. The series included 31 premature infants weighing less than 2,500 grams and 107 babies weighing less than 4,000 grams. Five attempts at cannulation failed. Each catheterization procedure required an average of 1.8 needle insertions before the vein was entered. In 129 patients, the first attempt was successful. Sixteen complications related to the procedure occurred early in our experience, seven of which were life threatening. One death was directly ascribed to the actual insertion of the catheter and mediastinal extravasation of infusion material. Most of the early complications probably could have been injected through the catheter immediately after cannulation, in addition to aspirating the blood and lowering the infusion bottle. The 22 late complications were related to infection; one infant died because of catheter sepsis. To minimize septic complications, an arbitrary limit of seven days was set, after which the catheter was replaced. Cannulation of the internal jugular vein in infants and children should be regarded as a serious surgical procedure to be performed by a trained team and only when properly indicated.     

Operative technique for insertion of a totally implantable system for venous access

A totally implantable venous access device is described and a step by step technique for implanting the device is given. Among 203 patients in whom the technique has been used, thrombosis of the subclavian or jugular vein has occurred in only three. There have been no pulmonary complications, and only three devices have been removed because of infection.     

In vivo noninvasive observation of acute mesenteric ischemia in rats

Acute intestinal ischemia remains a catastrophic event even with the advent of modern diagnostic and vascular surgical techniques. An early noninvasive test would be valuable since early operation yields better survival rates. We have used an in vivo rat model to study acute intestinal ischemia after occlusion of the superior mesenteric artery (SMA). 31Phosphorus magnetic resonance spectroscopy (MRS), a noninvasive nondestructive technique, can detect the phosphorus metabolites most likely to be altered in ischemia: adenosine triphosphate, phosphocreatine (PCr), inorganic phosphate (Pi) and phosphomonoesters and phosphodiesters. Furthermore, intracellular pH can be estimated from the pH dependent position of the Pi spectral line relative to PCr. A tourniquet was loosely placed around the SMA in five Wistar rats through a transabdominal approach to the retroperitoneum. The abdomen was immediately closed. A 20 millimeter MRS surface coil was placed on the abdomen and 31Phosphorus spectra were accumulated. The SMA was then occluded and additional 31Phosphorus spectra were taken for the next 75 minutes. Significant (p less than 10(-4) changes in the position and magnitude of the spectra lines occurred within 20 minutes; the Pi position indicates severe intracellular acidosis and rapidly increases to three times its original magnitude. The PCr line decreases in magnitude. In a similar experiment, occlusion of the superior mesenteric vein (SMV) produced equivalent results. Occlusion of vessels other than the SMA or SMV not accompanied by transmural ischemia resulted in spectra unaltered from control. These findings support the application of phosphorus MRS to clinical studies.     

Combined hepatic and pancreaticoduodenal procurement for transplantation

We have used a procurement method whereby both the liver and whole pancreas grafts are procured from the same donor and successfully transplanted. During the combined procurement, the hepatic artery is completely mobilized; the splenic artery is transected from the hepatic artery and the gastroduodenal artery is ligated from the hepatic artery. The portal vein is mobilized 2 centimeters from the head of the pancreas. The whole pancreas graft includes the splenic artery and the superior mesenteric artery, which are reconstructed. The hepatic graft includes the entire length of the hepatic artery with the celiac axis, and no further reconstruction is required. Using this technique, we have performed nine combined hepatic and whole pancreas procurements; only one liver was not transplanted because of technical complications. When a replaced right hepatic artery is identified from the superior mesenteric artery, we have abandoned the pancreatic retrieval. All combined retrievals have included successful renal retrieval, and the majority have been associated with cardiac retrieval also. Combined hepatic and whole pancreas procurement is feasible with minimal technical complications with the liver or the pancreatic graft and should be standard in most procurements.     

Prevention of intestinal infarction resulting from mesenteric arterial occlusive disease

We studied 25 patients with acute intestinal ischemia resulting from arteriosclerotic mesenteric occlusion requiring surgical exploration. Their symptoms were inconspicuous but diagnostically significant. Progressive loss of body weight and symptoms mimicking peptic ulcer disease or cholecystitis were consistent findings. Delay and oversight in the clinical diagnosis resulted in an 80 per cent mortality. We stressed that awareness of possible mesenteric arteriosclerosis in patients with ill-defined gastrointestinal symptoms and weight loss is critical to diagnosis, and early aortography done in the lateral position will define superior mesenteric arterial lesions. Early surgical corrective measures can then be instituted to remedy this critical and often fatal condition.     

Predicted value of renin activity in a woman who had severe ovarian hyperstimulation syndrome with internal jugular vein thrombosis

OBJECTIVE: To assess plasma renin activity in a patient with severe ovarian hyperstimulation syndrome (OHSS) and internal jugular vein thrombosis. DESIGN: Case report. SETTING: University-affiliated infertility center. PATIENT(S): A 33-year-old woman with OHSS and internal jugular vein thrombosis. INTERVENTION(S): Controlled ovulation hyperstimulation with recombinant FSH induction. MAIN OUTCOME MEASURE(S): Plasma renin activity (PRA), color Doppler ultrasound of the neck. RESULT(S): The patient had internal jugular vein thrombosis caused by severe OHSS. The PRA was significantly elevated during the acute stage and subsequently declined after resolution of the OHSS. CONCLUSION(S): In this patient elevated PRA appeared to be associated with the development of OHSS and thrombosis. The implication of the ovarian renin-angiotensin system in the development of OHSS and thrombosis is relevant.