Complications of anomalous origin of the right subclavian artery: Case report and review of the literature

A 35-year-old black woman presented with thrombosis of an anomalous right subciavian artery and distal arterial embolization. Initially, her right subclavian artery was reimplanted onto the common carotid artery, and a brachial artery embolectomy plus intraoperative thrombolytic therapy were used to reopen her distal arterial circulation. When her brachial artery repair thrombosed the following day, a distal ulnar artery bypass and repeat thrombolytic therapy were required to restore arterial patency. Six months later, she returned with severe, progressive, neointimal hyperplasia of her brachial artery and a second attempt at arterial reconstruction was unsuccessful. She eventually required a right below-elbow amputation. This patient demonstrated an anomalous right subclavian artery that presented with distal embolization without an antecedent history of severe atherosclerotic disease or the development of a right subclavian artery aneurysm. A review of the medical literature relating to complications of this anomaly is provided.     

Cross-femoral bypass graft for combined iliac arterial venous injury

We report on the treatment of a patient who sustained combined arterial and venous injury to the left iliac vessels as a result of a gunshot wound. Repair was accomplished as a staged procedure following lifesaving ligation of both artery and vein, using extraanatomic, cross-femoral polytetrafluoroethylene (arterial) and saphenous vein (venous) bypass techniques, followed by prophylactic caval filter placement. Principles of management with respect to combined arterial venous vascular injury are discussed, with special reference to controversies surrounding repair of major venous injury.     

THE DEVELOPMENT AND ENHANCEMENT OF THE COLLATERAL CIRCULATION IN AN ANIMAL MODEL OF LOWER LIMB ISCHAEMIA

In an animal model of hind limb ischaemia we documented the levels of endogenous basic fibroblast growth factor (bFGF) in control and ischaemic hind limbs, and evaluated the response to the administration of exogenous recombinant bFGF and heparin, Variations in this model were tested for their ability to alter the development of the collateral circulation. Recovery after acute arterial occlusion was significantly delayed by immediate bilateral mirror-image arterial ligations, when compared with either unilateral arterial ligation or delayed contralateral ligations performed after 2 months. If the major veins were also occluded all limbs developed gangrene, tissue loss and a marked delay in the recovery of blood flow, while none of the animals with unilateral arterial ligations developed gangrene. This indicates that the recovery in blood flow during the acute phase in this model is dependent on collateral vessels from the contralateral iliac artery and that major venous occlusion impedes the development of collateral vessels. Lumbar sympathectomy did not alter the recovery of blood flow after arterial occlusion, suggesting that collateral blood flow is not significantly influenced by autonomic neural supply. Following arterial occlusion there was a ten-fold increase in the levels of endogenous bFGF in all ischaemic muscle groups. Intramuscular implantation of bFGF in heparin-sepharose pellets at the time of arterial ligation markedly enhanced the blood flow for 3 weeks compared with untreated ischaemic limbs. A further increment in blood flow occurred if an additional dose of bFGF was administered 4 weeks after ligation. Administration of heparin for 1 week during either the acute or chronic phases of collateral development significantly improved the blood flow in ischaemic limbs. This was neither as profound nor as prolonged as that observed for bFGF. Treatment with heparin for 4 weeks following arterial ligation provide an increased blood flow for the first 3 weeks. These results indicate that tissues respond to ischaemia by an increased release of bFGF and that the evolution of collateral vessels can be enhanced by the administration of both exogenous recombinant bFGF and heparin. We conclude that bFGF is an important biochemical mediator in the development of the collateral circulation.     

An Alternative Technique in the Treatment of Celiac Axis Stenosis Diagnosed During Pancreaticoduodenectomy

Celiac compression is usually a benign condition, but when surgery necessitates division of collaterals from the superior mesenteric artery, it may cause life-threatening celiac organ ischemia. Celiac axis obstruction is found in 12.5% to 49.7% of patients during abdominal angiography. In such patients, the arterial blood supply to the stomach, spleen, and liver is sustained through extraordinarily welldeveloped pathways in the pancreas.Though collateral pathways may be sacrificed during pancreaticoduodenectomy, only a small proportion of patients develop hepatic, gastric and splenic ischemia during the procedure. If the appropriate angiographic studies have not been obtained before pancreatic resection, a test occlusion of the gastroduodenal artery, as recommended by Bull et al. [2], should precede its ligation. The hepatic arteries are palpated before and after the test occlusion. In the occasional patient in whom the pulse diminishes during occlusion or if there is evidence of upper abdominal visceral ischemia, revascularization of the celiac circulation may be required. Reestablishment of the celiac circulation may be accomplished by the use of a vein graft between the aorta and the celiac tributaries. This article describes an alternative technique for revascularization of the celiac circulation without the use of a venous graft.     

腹主动脉瘤腔内修复术中封闭髂内动脉后的并发症及其与侧支血管形成的关系

背景与目的：腹主动脉瘤腔内修复术（EVAR）由于其安全性和有效性,已逐步成为腹主动脉瘤的一线治疗方法,虽然目前已有各种微创腔内器具和介入技术运用于髂内动脉（IIA）的保留,但临床上需封闭IIA的情况仍不少见,而一旦封闭IIA,尤其进行双侧IIA栓塞的患者,可能出现臀肌缺血、肠道缺血、性功能障碍等并发症。同时,部分IIA侧支建立良好患者行双侧IIA封闭后无明显封闭相关并发症的发生。因此,本研究探讨分析EVAR中封闭单侧或双侧IIA后,臀肌、肠道、生殖器缺血等并发症情况及其与侧支代偿之间的关系。方法：回顾性收集并分析2011年7月—2021年7月在中国人民解放军海军军医大学附属长海医院行EVAR的1 902例患者的基线资料及术前、术中、术后影像学资料,筛选出426例行IIA封闭的患者（62例行双侧IIA封闭,264例行单侧IIA封闭）,并进行并发症相关症状电话随访。统计患者围手术期和随访期患者臀肌缺血、肠道缺血、性功能障碍等相关并发症情况,根据术中及术后影像观察侧支代偿情况,并分析侧支建立与并发症的关系。结果：426例患者中,73例（17.1%）出现臀肌缺血症状,7例（1.6%）出现肠道缺...     

Acute ligation of the radial and ulnar arteries: A case report and review of literature

Isolated injury to the radial or ulnar artery results in no significant complications in patients who undergo repair or ligation of the injured artery. However, ligation of both infrabrachial vessels of the upper extremity is associated with limb loss from ischemia due to lack of collateral circulation. A rare case of acute ligation of both the radial and ulnar arteries in a drug abuser where collateral vessels preserved the circulation to the hand is reported.     

Functional effect of collateral circulation after dearterialization of the liver

The functional effect of the collateral circulation after hepatic dearterialization was investigated in dogs with end-to-side portacaval shunt after ligation of hepatic artery. The functional effect of collateral circulation was far less than that of the native hepatic artery even for one week after occlusion of the common hepatic artery. However the functional effect of the collateral blood flow suddenly rose to the level of that of native hepatic artery one week after ligation of common hapatic artery or two weeks after ligation of proper hepatic artery.     

A new model for intestinal ischemia in the rat

Many models of intestinal ischemia in the rat have been described yielding mortality rates of 8-80% following superior mesenteric artery (SMA) occlusion for periods of 1-85 min. These results have been difficult to reliably reproduce in our lab. Based on our theory that these inconsistent findings are secondary to individual variability in collateral circulation, we have developed a new model for intestinal ischemia with reproducible and consistent mortality. Male Sprague-Dawley rats weighting 300-400 g underwent celiotomy and evisceration. Occlusion of the superior mesenteric artery just distal to the right colic artery was achieved. Collateral arcades from the right colic artery and the jejunal arteries proximal to the site of occlusion were ligated and the bowel was returned to the abdomen for the remainder of the ischemic period. SMA occlusion alone and SMA occlusion with interruption of collateral flow were evaluated and compared for severity of ischemic injury reflected by mortality and for reproducibility of ischemia and mortality. Quantitative measurements of blood flow for each technique were made using radiolabeled microspheres, and a survival curve for SMA occlusion with collateral ligation was constructed. SMA occlusion alone in the rat is not a reliable model for mesenteric ischemia because the resulting ischemic injury is inconsistent and not reproducible. SMA occlusion with collateral ligation produced more severe and reproducible ischemia with greater mortality than did SMA occlusion alone. This technique produced mortality rates that were reproducible and were more consistently related to duration of ischemia.     

Utilization of skin flap for reconstruction of the genitalia after an electric burn

The objective of this article is to describe a case of an electric burn to the genitalia causing scrotal and testicular lesion, and the subsequent reconstruction using a skin graft. The patient was a 10-year-old boy who was victim of an electric burn that harmed the genitalia. There was extended skin loss, penile, scrotal and partial testicular lesion. The treatment consisted of plastic surgery to reconstruct the genitalia with skin flaps grafted on the left thigh, the scrotum and the base of the penis. The patient recovered well and was discharged after two weeks. We concluded that in severe cases of electric burns to the genitalia, skin graft offer a good therapeutic option.     

The effects of dichloroacetate in a rabbit model of acute hind-limb ischemia and reperfusion

BACKGROUND: Dichloroacetate (DCA) is a drug that allows pyruvate dehydrogenase to remain active under anaerobic conditions by inhibiting the inactivating enzyme, pyruvate dehydrogenase kinase. We hypothesize that the administration of DCA during acute limb ischemia may have a beneficial effect by reducing the severity of anaerobic metabolism and lessening the irreversible injury. STUDY DESIGN: We studied a rabbit model using unilateral ligation of the iliac artery or femoral artery to evaluate two degrees of ischemia. After 2 hours of hind-limb ischemia, the animals were administered IV DCA (15 mg/kg) or an equivalent volume of saline. RESULTS: Higher serum lactate levels were seen after high compared to low ligation in control animals consistent with more severe ischemia. DCA treatment significantly reduced serum lactate levels after both high and low ligation. Similarly, the rise in percentage end-tidal CO(2) after reperfusion was less after DCA. All animals regained hind-limb function after the procedure, but ischemia or reperfusion resulted in appreciable muscle necrosis (> 10% area) in 50% of high- and 22% of low-ligation control animals. DCA treatment eliminated significant muscle necrosis in 100% of high-ligation animals. Muscle histology was similar in control and DCA-treated low-ligation animals. CONCLUSIONS: Treatment with DCA during acute arterial occlusion did significantly lower markers of anaerobic metabolism and reduced muscle necrosis in a rabbit model of acute hind-limb ischemia. DCA delivery through collateral blood flow may prolong the ischemia time interval before the onset of irreversible muscle injury and potential limb loss.     

Traumatic penile partial amputation caused by rubber band a case report

Introduction and importanceTraumatic amputation of the penis is a rare surgical emergency. Penile amputation is usually caused by self-mutilation, accidents, circumcision, assault and animal attacks. Accidental injury covers a large portion of external genitalia trauma because of its high prevalence and severity of this disease. Here, we report the case of a 21-year-old man who underwent replantation of his self-inflicted partial amputated penis.Case presentationWe report a case of traumatic penile partial amputation in a 21-year-old man with a history of mental retardation that presented with a one-day history of pain on the penile shaft due to tied penile shaft with a rubber band ten days prior. Genitalia examination showed a partial amputation at the penis shaft region. Reconstruction microsurgery and debridement on the penile shaft and urethral anastomosis were performed. This case highlights the management of traumatic penile partial amputation. The urethral anastomosis and penile replantation were successfully done.Clinical discussionPenile amputation is a rare urological emergency. Most of the cases reported with self-mutilation are a result of severe substance-induced psychosis or underlying psychiatric disorder. Factors that contribute to the successful penile replantation include the severity of the penile injury or amputation, type and mechanism of injury, team expertise available, duration of ischemia time, and use of a microscope at the time of neurovascular bundle repair.ConclusionA traumatic penile partial amputation is a rare urologic emergency. Self-inflicted amputation is often found in a patient with a history of psychological or mental illness. The limited data on detailed best surgical measures and outcomes is still a concern.     

Revascularization of the kidney after occlusion of the aorta and both renal arteries.

A patient who developed acute renal artery thrombosis as a complication of distal abdominal aortic occlusion is described. Because of the presence of an extensive collateral arterial supply, the right kidney survived and revascularization was accomplished successfully with a saphenous vein graft interposed between the superior mesenteric and the right renal arteries. Criteria for revascularization of renal artery occlusion are presented, with emphasis on the importance of collateral circulation and the elective correction of distal aortic thrombosis.     

Vertebral artery reconstruction: Results in 106 patients

Between January 1982 and December 1989, we performed 109 revascularizations of the vertebral artery in 106 patients. Eighty-six patients (81%) had isolated vertebrobasilar insufficiency, 18 (17%) had associated carotid and vertebrobasilar pathology while two (2%) had isolated carotid symptoms. The procedures performed included 98 revascularizations of the proximal vertebral artery and 11 reconstructions of the distal vertebral artery. One distal revascularization was required after early failure of proximal revascularization. In 36 cases (34%), a concomitant ipsilateral carotid artery revascularization procedure was performed, and in one case, an ipsilateral subclavian artery aneurysm was excised. Two patients (1.9%) died post-operatively and five patients (4.7%) had nonfatal neurologic complications. Four of these seven complications occurred after combined vertebral and carotid surgery. One hundred early follow-up arteriograms were obtained (92% of reconstructions). There were four occlusions, two of which were associated with neurologic deficits. Three patients were lost to follow-up. Mean follow-up was 48 months (4–100 months). Seven patients died in the late follow-up period (after one month). Actuarial five year survival was 91%. Overall patency at five years was 96%. The study of late neurologic events showed that 63% of patients had complete recovery, 30% improvement, and 7%, failure or aggravation of symptoms.Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, May 18–19, 1990, Nancy, France.     

Femorofemoral crossover bypass for noninfective complications of aortoiliac surgery

Between 1973 and 1989, 39 femorofemoral crossover bypasses were performed to treat unilateral noninfective complications of aortoiliac surgery. The initial revascularization procedure, performed an average of 79.5 months previously, was an aortobifemoral bypass in 29 cases, an aorto- or iliofemoral bypass in six cases, an inlay graft for abdominal aortic aneurysm and aortoiliac endarterectomy in two cases each. The indications for femorofemoral crossover bypass included prosthetic occlusion in 35 cases, thrombosed false aneurysm in two, and further degradation after endarterectomy (iliac stenosis and occlusion in one case each). There was no operative mortality. One patient with acute ischemia upon admission and another with distal gangrene required below-knee and forefoot amputations, respectively. No amputations were required during the rest of the follow-up period. Three repeat aortobifemoral bypasses were performed because of occurrence of aortic or inflow vessel lesions. Primary and secondary actuarial five year patency rates for femorofemoral crossover bypasses were 59.7% and 78.4%, respectively. Femorofemoral crossover bypass can extend the benefits derived from direct aortoiliac surgery with low mortality and morbidity in the absence of associated aortic pathology (false aneurysm at the aortic implantation site or severe obstructive lesions). kg]Key wordsPresented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, May 18–19, 1990, Nancy, France.     

Simultaneous aortic and renal artery reconstruction for acute arterial occlusion in solitary kidney

A case is described of the onset of acute renal failure due to renal artery occlusion in a solitary kidney of a sixty-six-year-old woman. She had been treated for severe hypertension due to renal artery stenosis. An aortorenal bypass to revascularized the kidney was combined with repair of an abdominal aortic aneurysm. There was early and full recovery of renal function in the single kidney, and the patient was completely rehabilitated. Review of the literature shows that an aggressive surgical approach to the management of renal artery occlusion is usually followed by excellent results. The pre-existence of renal artery stenosis encourages the formation of a collateral arterial supply which maintains the nutrition of the kidney almost indefinitely, after renal artery occlusion. Revascularization will result in prompt recovery of renal function.     

Perioperative implications of retrograde flow in both the subclavian arteries in an adult undergoing surgical repair of coarctation of aorta

During surgical repair of coarctation of aorta (CoA), management of spinal cord ischemia and prevention of paraplegia is an important issue. The risk factors for paraplegia include level and duration of aortic-clamping, clamping of left subclavian artery (SCA), intraoperative temperature, variability of collateral circulation to the spinal cord, cerebrospinal fluid pressure, upper body arterial pressure, and aortic pressure beyond the aortic clamp. A short clamp time (<30 min), and distal aortic pressure>60 mmHg, minimizes the risks of spinal cord injury. In an adult patient during surgical repair of CoA, the arterial pressure in the femoral artery remained around 45 mmHg and repair took 83 min of aortic-clamping. Neurological assessment on regaining consciousness showed no deficit of lower limbs. Aortic root angiogram had shown retrograde filling of both SCAs. A unique situation in which clamping of SCAs would increase flow to the spinal cord as their clamping would stop stealing of blood and aortic-clamping proximal to CoA will further increase collateral flow; because of these reasons, the patient tolerated prolonged aortic-clamping despite low distal aortic pressure without neurological deficit. However, aortic-clamping increased left ventricular after-load and the patient developed worsening of mitral regurgitation and pulmonary hypertension during aortic clamping.     

Common carotid occlusion for unclippable carotid aneurysms: an old but still effective operation

We present a selected series of nine patients with unclippable internal carotid artery aneurysms to illustrate our current approach to this problem. Eight of the nine underwent common carotid ligation after preoperative angiographic evaluation. Tolerance to carotid occlusion was determined intraoperatively by awake examination, electroencephalogram (EEG) monitoring, and carotid stump pressure measurements. No patient developed a permanent deficit; seven of eight treated aneurysms have thrombosed. Our experience and review of the literature indicate that most ischemic complications after carotid ligation seem to be thromboembolic, rather than due to "low flow" from poor collateral circulation. For this reason, we have gradually come to favor common carotid (CCA) over internal carotid (ICA) occlusion in many of these patients. After CCA occlusion, the ICA frequently remains open and embolic complications are therefore less likely. An extracranial-intracranial bypass procedure is performed only in those patients with poor collateral circulation demonstrated by cross compression angiographic studies, by the development of new deficits during test occlusion, or by the appearance of EEG changes during test occlusion. We suggest that CCA ligation remains a useful alternative in the management of unclippable internal carotid aneurysms.     

Chylous ascites following abdominal aortic surgery

Three patients, two women, one man (mean age 74 years), who had abdominal aortic aneurysms (2) or aortobifemoral surgery (1), developed chylous ascites postoperatively. They were studied to determine their clinical course and develop a plan for management of this complication. In each patient, the ascites was not manifest until abdominal swelling developed two weeks after operation, and the problem was confirmed by the finding of milky fluid on paracentesis. A low serum albumin (mean 2.6 gm) was also characteristic. The ascites was not altered by parenteral nutrition or reduction of dietary fat and ingestion of medium chain triglycerides. In one patient (man, age 93) the ascites resolved spontaneously two months after abdominal aortic aneurysm surgery. Another (woman, age 70) was cured following operative ligation of a lymphatic fistula identified at operation five weeks after abdominal aortic aneurysm repair. In the third (woman, age 60), the ascites resolved immediately following placement of a peritoneal venous shunt six weeks after an aortobifemoral bypass. Chylous ascites is rare after aortic surgery and manifests itself about two weeks after operation, at times after discharge from hospital. It has an indolent course, but may resolve spontaneously up to two months after operation. Its course appears not to be foreshortened by diet, including omission of fat, but can be successfully treated surgically with a shunt or fistula ligation. If done early a protracted hospital course may be avoided. Presented at the Ninth Annual Meeting of the Southern California Vascular Surgical Society, Newport Beach, California, September 22, 1990.     

Late upper extremity embolic complications of occluded axillofemoral grafts

The use of axillary femoral grafting in the treatment of patients at high risk for aortoiliac reconstruction has become a widely accepted treatment modality. Ischemia and even loss of the donor upper extremity have been reported to occur early after graft occlusion. This report describes three patients who developed emboli to the upper extremity at nine, 15, and 34 months following occlusion of their axillary femoral graft. Based on our experience, we consider an occluded axillofemoral graft a permanent threat to the viability of the donor upper extremity. Anatomic changes suggestive of potential ischemia include: presence of a blind pouch in the graft stump, or Y elongation of the artery with proliferative changes in the intima.     

Acute pancreatitis following aortic aneurysm repair: Report of three cases

This paper reports three cases of acute pancreatitis that occurred after repair of an abdominal aortic aneurysm. The aneurysms were ruptured in two patients and asymptomatic in one. No patient had biliary disease or history of pancreatitis or alcohol abuse. Two of the patients required operation for drainage and debridement; one died. The etiology and diagnosis are discussed.