Clinical results of deep venous valvular repair for chronic venous insufficiency*

Objective

To evaluate the results of venous valvular repair in the treatment of 16 cases of chronic venous insufficiency (CVI).

Design

A retrospective analysis of 16 venous valve repair operations (15 patients) with a minimum follow-up of 2 years.

Setting

A 650-bed university-affiliated teaching hospital.

Patients

Fifteen consecutive referred patients who had CVI had deep vein valve surgery. All cases were refractory to prolonged conservative care and removal of incompetent superficial and perforating veins. Investigation included ascending and descending venography, air plethysmography (APG) and colour flow duplex scanning (CFDS). All patients had class 4, 5 or 6 CVI and all demonstrated deep venous reflux from the groin to below the knee on descending venography.

Interventions

Superficial femoral vein valvuloplasty (12 operations) and venous valve transfer from the axillary vein to the above-knee popliteal vein (4 operations).

Main outcome measures

Healing of ulcers, relief of edema and improvement in symptoms were clinical criteria of success. An attempt was made to correlate preoperative and postoperative APG, CFDS and descending venography.

Results

Ninety-two percent of the valvuloplasty patients and 75% of the valve transfer patients were clinically improved. In this series no statistical association existed between preoperative and postoperative changes noted on APG.

Conclusion

This series suggests that deep vein valvular reconstruction for CVI refractory to conservative management and superficial surgery offers a good chance of clinical improvement.     

MicroRNA-155 promotes neointimal hyperplasia through smooth muscle-like cell-derived RANTES in arteriovenous fistulas

Objective

Arteriovenous fistula (AVF) suffers from a high number of failures caused by insufficient outward remodeling and venous neointimal hyperplasia formation. The aim was to investigate the exact mechanism by which microRNA-155 (miR-155) in the outflow vein of AVF is regulated.

Distal revascularization and interval ligation (DRIL) procedure requires a long bypass for optimal inflow

Background

Distal revascularization and interval ligation (DRIL) is commonly used to treat ischemic steal syndrome caused by arteriovenous hemodialysis access and has been associated with good outcomes. However, the literature lacks technical details of a successful intervention. We tested the hypothesis that a brachial-level arteriovenous fistula (AVF) generates a zone of low arterial blood pressure in the brachial artery near the AVF origin.

Methods

We identified patients with ischemic steal syndrome caused by an AVF originating from the brachial artery level who were eligible for the DRIL procedure. All patients were studied with invasive pressure monitoring in the brachial artery at the time of digital subtraction angiography. We measured systolic, diastolic and mean arterial blood pressure at 5 cm intervals from a point in the arterial circulation 5 cm distal to the origin of the AVF and continuing proximally into the subclavian artery.

Results

Our series involved 10 patients with a mean age of 66.5 (range 53–81) years. Four patients were women and 8 had diabetes. All patients had grade 3 ischemic steal syndrome with ischemic rest pain and/or ischemic tissue loss. Mean systolic, diastolic and arterial pressures increased from the level of the AVF until central pressures were reached. Systolic blood pressure was significantly lower than central blood pressure until a level 20–25 cm proximal to the AVF.

Conclusion

The benefits of the DRIL procedure in alleviating ischemic steal syndrome associated with hemodialysis access are best achieved with a DRIL bypass for which inflow originates at least 20–25 cm proximal to the origin of the AVF.     

A short course of low-molecular-weight heparin to prevent deep venous thrombosis after elective total hip replacement

Objective

To determine the efficacy of a short course of low-molecular-weight heparin (enoxaparin) in the prevention of deep venous thrombosis and pulmonary embolism after elective total hip replacement.

Design

A prospective cohort study. Follow-up was a minimum of 3 months.

Setting

An acute-care hospital with a large-volume practice of elective total joint replacement.

Patients

A prospective group of 150 patients who required primary total hip arthroplasty and a historic control group of 150 patients. All patients were treated with compression stockings, indomethacin and early mobilization. The treatment group received low-molecular-weight heparin, 30 mg every 12 hours for 5 days postoperatively; the control group received no specific anticoagulant therapy.

Interventions

Total hip replacement. Doppler venography on postoperative day 5 and 2 to 5 days later if required.

Main outcome measures

Presence or absence of deep venous thrombosis. Wound hemorrhage, transfusion rate, number of units of blood transfused and changes in the hemoglobin level.

Results

The incidence of proximal deep venous thrombosis (popliteal vein to common iliac vein) was 0% in the treatment group versus 4% in the control group. There was no difference in bleeding or number of transfusions required. There was, however, a significant (p = 0.005) drop in hemoglobin level in the treatment group.

Conclusions

A short course of low-molecular-weight heparin provides effective protection against proximal deep venous thrombosis without significantly increasing the risk to the patient. The treatment is compatible with early patient discharge and the pharmacologic prevention of heterotopic ossification after total joint replacement.     

Phyllodes tumor metastasis to the tonsil with synchronous undifferentiated carcinoma

INTRODUCTION

Breast tumor metastasis to the tonsil is extremely rare.

PRESENTATION OF CASE

A 54-year-old woman underwent resection of a breast malignant phyllodes tumor and later presented with metastasis to the lung and the left tonsil. She underwent left lower lobectomy and resection of the left tonsillar tumor. She subsequently developed undifferentiated carcinoma of the right tonsil. She underwent resection of the right tonsillar tumor and chemotherapy was started. The central venous catheter became infected with methicillin-resistant Staphylococcus aureus. Finally, she died.

DISCUSSION

To the best of our knowledge, this is the first reported case of a phyllodes tumor metastasizing to the tonsil. Furthermore, morphological and immunohistochemical study revealed that the right tonsillar tumor was irrelevant to the phyllodes tumors.

CONCLUSION

We report a case of phyllodes tumor metastasis to the left tonsil which developed undifferentiated carcinoma in the other side of tonsil later. Breast tumor metastasis to the tonsil is rare but it should be considered as a possible diagnosis.     

Iatrogenic Combined Bile Duct and Right Hepatic Artery Injury During Single Incision Laparoscopic Cholecystectomy

Background:

Numerous recent reports describe the performance of laparoscopic procedures through a single incision. Although the feasibility of this approach for a variety of procedures is currently being established, little data are available regarding safety.

Case Report:

A 65-year-old female patient who was transferred from an outside institution had undergone a single incision laparoscopic cholecystectomy that resulted in biliary tract and vascular injuries.

Methods:

The patient was transferred with a known bile duct injury on the first postoperative day following single incision laparoscopic cholecystectomy. Review of her magnetic resonance imaging and percutaneous transhepatic cholangiogram studies showed a Bismuth type 3 bile duct injury. Hepatic angiogram demonstrated an occlusion of the right hepatic artery with collateralization from the left hepatic artery. She was initially managed conservatively with a right-sided external biliary drain, followed 6 weeks later by a Hepp-Couinaud procedure to reconstruct the biliary tract.

Conclusion:

As new techniques evolve, it is imperative that safety, or potential side effects, or both safety and side effects, be monitored, because no learning curve is established for these new techniques. In these initial stages, surgeons should have a low threshold to add additional ports when necessary to ensure that procedures are completed safely.     

Effects of Acute Nitric Oxide Synthase Inhibition on Lower Leg Vascular Function in Chronic Tetraplegia

Background/Objective:

To improve our understanding of the lower-leg vascular responses of nitric oxide synthase inhibition in persons with tetraplegia.

Participants:

Six people with chronic tetraplegia and 6 age-matched controls.

Methods:

Lower-leg relative vascular resistance and venous volume variation were obtained by venous occlusion plethysmography and blood pressure by auscultation at baseline. Postintravenous infusion of the nitric oxide synthase inhibitor N^G-nitro-l-arginine-methyl-ester (1 mg·kg⁻¹) or placebo on separate days.

Results:

At baseline in the group with tetraplegia compared with controls, mean arterial pressure and relative vascular resistance of the leg were significantly lower. After nitric oxide synthase inhibition, mean arterial pressure and lower leg vascular resistance were significantly elevated in both groups. There were no group or intervention differences in venous volume variation.

Conclusion:

These preliminary results suggest that nitric oxide synthase inhibition with 1 mg·kg⁻¹ N^G-nitro-l-arginine-methyl-ester normalizes seated blood pressure and lower leg vascular resistance to control group baseline levels.     

Patterns of arteriosclerotic lesions of the lower extremity in a West Indian population based on angiographic findings and ethnicity

Introduction

This study aimed to determine whether ethnic differences show different patterns of arterial disease in the lower limb.

Methods

A prospective analysis of 100 consecutive patients with 160 lower limb arteriograms was performed looking at the pattern of disease with relation to ethnicity in Trinidad and Tobago.

Results

There were 53 male and 47 female patients with an age range of 43–90 years (mean: 66 years). Of the 100 patients, 45 were of East Indian descent, 36 of Afro-Caribbean descent, 14 of mixed descent and 5 had other backgrounds. There were 32 smokers and 69 diabetics.The most commonly affected artery in East Indians was the anterior tibial artery (ATA, 70%) followed by the peroneal artery (60%), superficial femoral artery (SFA, 60%), posterior tibial artery (PTA, 57%) and tibioperoneal trunk (TPT, 39%). In Afro-Caribbeans, the most commonly affected artery was the ATA (79%) followed by the PTA (74%), peroneal artery (66%) and TPT (55%). The mixed group showed the PTA (85%) to be most diseased followed by the peroneal artery (75%), ATA (70%), SFA (70%), dorsalis pedis artery (DPA, 60%) and TPT (50%). Overall, the most diseased vessel in all groups was the ATA (73%) followed by the PTA (66%), peroneal artery (64%), SFA (59%), TPT (46%), DPA (38%), popliteal artery (31%) and medial plantar artery (MPA, 29%), with the proximal vessels not being affected severely.

Conclusions

Ethnic divisions were only statistically significant (p<0.05) with East Indians showing worse disease in the profunda femoris artery and Afro-Caribbeans showing worse disease in the PTA, DPA and MPA. This suggests that environmental factors may play a significant role in the disease process including smoking and dietary factors rather than purely genetics.     

Prospective long-term study of patency and outcomes of 505 arteriovenous fistulas in patients with chronic renal failure: Authors experience and review of literature

Background:

This study describes our experience of arteriovenous fistula (AVF) creation as vascular access for haemodialysis.

Materials and Methods:

This study has been carried out in our hospital from January 2004 to December 2012. A total of 505 AVFs were created in 443 patients. Maximum follow-up was 8 years, and minimum was 6 months.

Observations and Results:

In this study of 505 cases of AVFs, primary patency rates by Kaplan — Meier analysis showed 78.81% patency of fistulas at the end of 1 year and patency dropped to 14.81% at the end of 5 years. Our primary failure rate was 21.2%. Basilic vein was used in 26.35% cases, cephalic vein in 63.5%, and antecubital vein in 9.75% cases. On table, bruit was present in 459 (90.9%) and thrill in 451 (89.3%) cases. During dialysis, flow rate >250 ml/min was obtained in 150 (29.9%) cases. In complications, 2 (0.4%) patients developed distal oedema, 33 (6.5%) developed steal phenomenon.

Conclusions:

Presence of on table thrill and bruit are indicators of successful AVF. If vein diameter is <2 mm, chances of AVF failure are high. Flow rates in patients with vein diam. >2 mm were significantly higher as compared with patients with vein diam. <2 mm (P < 0.001). Flow rates are higher in non-diabetic patients as compared to diabetic patients (P < 0.001). Average blood urea and serum creatinine values are significantly lesser in patients undergoing dialysis through successful fistulas as compared to patients with failed fistulas. Correspondingly, incidence of deaths is significantly lesser in patients with successful fistulas. During proximal side-to-side fistula between antecubital/basilic vein and brachial artery, dilating of the first valve toward wrist helps to develop distal veins in the forearm by retrograde flow. This technique avoids requirement of superficialization of basilic vein in the arm.KEY WORDS: Arteriovenous fistula, chronic kidney disease, haemodialysis, vascular access     

Intraoperative venous congestion in free transverse rectus abdominis musculocutaneous and deep inferior epigastric artery perforator flaps during breast reconstruction: A systematic review

BACKGROUND:

Even with patent deep inferior epigastric vein anastomoses, venous congestion can occur during free transverse rectus abdominis musculocutaneous (TRAM) or deep inferior epigastric artery perforator (DIEP) flap surgery and lead to flap compromise if not recognized and managed.

OBJECTIVES:

To identify the incidence of intraoperative venous congestion and describe the best available prevention and treatment methods.

METHODS:

Systematic electronic searches of the PubMed database including Medline were performed to identify studies published until 2014. The following keywords were used: “DIEP” or “free TRAM” and “venous insufficiency” or “venous congestion”. Supplemental searches were conducted to identify referenced studies. Statistical analysis using the χ² test was performed.

RESULTS:

Nine studies representing 4747 free abdominal flaps cases were included and demonstrated an overall incidence of intraoperative venous congestion of 2.8%. The incidence in DIEP flaps (3.3%) was significantly higher than that in the free TRAM flaps (1.0%). All nine articles reported using the superficial inferior epigastric vein to treat venous insufficiency.

CONCLUSION:

The risk for developing intraoperative venous congestion following free abdominal flap breast reconstruction is influenced by inadequate perforator selection and persistent dominance in the superficial venous system. The solution is establishing another venous draining route using the superficial inferior epigastric vein.     

Dysphagia lusoria: extrathoracic surgical management

Objective

To report a case of dysphagia lusoria managed by an extrathoracic approach.

Design

Case report and literature review.

Setting

A university hospital.

Patient

A 39-year-old man, who presented with weight loss and dysphagia. Aortography and computed tomography revealed an aberrant subclavian artery compressing the esophagus against the aortic arch.

Intervention

The right subclavian artery was divided at its origin and reimplanted onto the right carotid artery. The operation was performed through a right supraclavicular incision without opening the chest.

Results

There was no operative morbidity. Six months postoperatively the patient was asymptomatic and had gained weight. There was no radiologic evidence of esophageal compression.

Conclusions

Based on the results of our case of dysphagia lusoria and the reports of others that have started to appear in the literature, consideration should be given to repairing a symptomatic, nonaneurysmal aberrant right subclavian artery through an extrathoracic approach.     

The indications and reliability of vein graft use in free flap transfer

BACKGROUND:

Adequate recipient vessels are critical for free flap success. There are, however, situations in which the local recipient vessels are inadequate. In these situations, vein grafts are required to allow pedicle extension to recipient vessels.

OBJECTIVES:

To determine the indications, technique, reliability and outcome of vein graft use in free flap transfer.

METHODS:

A retrospective review of 198 consecutive free flaps by a single surgeon.

RESULTS:

Vein grafts were required in 9.6% of free flaps. The most common indication was vein graft use in a planned preoperative fashion. The vein graft was most commony placed as an arteriovenous fistula loop. There was no statistically significant difference in survival between flaps with or without vein grafts.

CONCLUSION:

Vein graft use in free flap transfer is reliable, effective and often necessary for free flap survival.     

A complex fistula-in-ano presenting as a soft tissue tumor

INTRODUCTION

Anorectal abscess and fistula are quite commonly encountered diseases. Both of these are the acute and chronic manifestations of the same entity. While abscess are thought to begin as an infection in the anal glands, their spreading into adjacent spaces results in a fistula formation. At many times this spread occurs in a complex pattern which is difficult to map and treat.

PRESENTATION OF CASE

This paper describes a complex perianal fistula that presented as a painless benign lump in the upper outer quadrant of the right buttock. The lump initially thought to be a soft tissue swelling was later diagnosed to be a chronic abscess cavity extending medially toward the anal canal in the form of a complex fistulous tract.

DISCUSSION

Complex perianal fistulas are difficult to treat and are prone to recurrences. Correct diagnosis and characterization of the fistula is essential to optimize the treatment. Clinical examination alone may not give a correct picture of the actual disease, thereby requiring radiological investigations like MRI.

CONCLUSION

Although rare, sometimes common clinical conditions like fistula-in-ano may also present in complex manner. It is important to establish the diagnosis firmly and map the fistula properly before going in for surgery. Complexity of fistulas and improper mapping often leads to recurrences and other complications like incontinence.     

Minimally invasive cardiac surgery for removal of the greater saphenous vein

Objective

To determine if saphenous vein required for coronary bypass could be quickly, easily and safely removed with a minimally invasive technique.

Design

A consecutive series.

Setting

A university centre.

Material and Methods

In cadavers, a standard mediastinoscope was used to remove segments of the greater saphenous vein. Thigh segments, superior leg segments and ankle segments were removed. Fifteen minutes were allowed for removal of a segment.

Results

Segments of vein 15 to 17 cm long could be removed. One segment could not be removed within 15 minutes. Thigh segments were easy to remove, calf segments were the most difficult. There were no avulsed side branches. All incisions were less than 5 cm long.

Conclusions

Saphenous vein can be harvested quickly and safely by a minimally invasive method. Lower extremity complications may be reduced and long-term patency improved with this in-situ technique of vein removal.     

Case report: The operation for the lumbar disk herniation just after cesarean delivery in the third trimester of pregnancy

INTRODUCTION

Low back pain is common during pregnancy. However, the incidence of symptomatic lumbar disc herniation during pregnancy is very rare. We report a case of lumbar disc herniation underwent discectomy just after cesarean delivery in the third trimester of pregnancy.

PRESENTATION OF CASE

A 33-year-old woman presented at 32 weeks gestation. She had a low back pain and the left-sided leg pain below the knee. At 34 weeks gestation, she had severe weakness of the left extension halluces longus, left ankle dorsiflexion. MRI showed a large disc herniation at L4/5 expanded to the spinal canal more. The cesarean delivery was performed in the supine position. The patient was then turned to a prone position, and a left L4/5 discectomy was performed. But the day after surgery, she had a severe low back pain and the right leg pain below the knee. MRI showed a disc herniation at L4/5 on the right side of the spinal canal. At 6 days after the first surgery, a right L4/5 discectomy was performed. In the immediate postoperative period, the patient experienced complete relief of the right leg pain.

DISCUSSION

It is necessary to cooperate with a pediatrician, an obstetrician, and an anethesiologists. For obtaining the best outcome on mother and child, it is important to discuss in advance to be able to respond quickly for changeable situation.

CONCLUSION

It is necessary to conduct the operation under pregnancy in consideration of the great influence on mother and child.     

Arteriovenous fistula combined with brachial artery superficialization is effective in patients with a high risk of maturation failure

Objective

In patients with a high risk of fistula immaturity, we created arteriovenous fistulas (AVFs) combined with brachial artery superficialization. With this procedure, the superficialized arteries are used as drawing routes and the AVFs as returning routes. This is a technical report about AVFs combined with brachial artery superficialization.

Management of subclavian-axillary vein thrombosis: a review

Objective

To study, by literature review, the management of subclavian-axillary vein thrombosis (SAVT) and to make recommendations.

Data sources

The MEDLINE database and cross-referenced articles.

Study selection

Key words subclavian-axillary vein thrombosis, venous thrombosis, Paget–Schroetter syndrome, anticoagulation, and thrombolysis were used to extract articles related to SAVT.

Data extraction

Independent extraction of articles by 2 observers.

Data synthesis

Although numerous studies are available in the literature, they vary widely in their patient selection, treatment methods, follow-up and conclusions. As such, the management of patients with SAVT remains controversial.

Conclusions

Anticoagulation remains the initial treatment of choice for acute SAVT although there is definitely a role for thrombolysis and surgery in selected cases. Surgical intervention should be reserved for patients in whom there is a specific indication. Since chronic symptoms depend largely on the etiology of the disease, treatment should be tailored to address the causative factors. A multicentre, prospective study is necessary to evaluate the optimum management strategies for patients with SAVT.     

Nephron-sparing surgery for treatment of reninoma: a rare renin secreting tumor causing secondary hypertension

Main findings

A 25-year-old hypertensive female patient was referred to our institution. Initial workup exams demonstrated a 2.8 cm cortical lower pole tumor in the right kidney. She underwent laparoscopic partial nephrectomy without complications. Histopathologic examination revealed a rare juxtaglomerular cell tumor known as reninoma. After surgery, she recovered uneventfully and all medications were withdrawn.

Case hypothesis

Secondary arterial hypertension is a matter of great interest to urologists and nephrologists. Renovascular hypertension, primary hyperadosteronism and pheocromocytoma are potential diagnosis that must not be forgotten and should be excluded. Although rare, chronic pyelonephritis and renal tumors as rennin-producing tumors, nephroblastoma, hypernephroma, and renal cell carcinoma might also induce hypertension and should be in the diagnostic list of clinicians.

Promising future implications

Approximately 5% of patients with high blood pressure have specific causes and medical investigation may usually identify such patients. Furthermore, these patients can be successfully treated and cured, most times by minimally invasive techniques. This interesting case might expand knowledge of physicians and aid better diagnostic care in future medical practice.     

Arteriovenous fistulas for microvascular head and neck reconstruction

BACKGROUND:

In head and neck cancer patients, multiple surgeries and radiation can leave the neck depleted of recipient vessels appropriate for microvascular reconstruction. The creation of temporary arteriovenous fistulas using venous interposition for subsequent microvascular reconstruction has rarely been reported in the head and neck. The authors report the largest series of temporary arteriovenous loops for head and neck reconstruction in vessel-depleted necks.

METHODS:

The authors performed a case series of major head and neck reconstructions using temporary arteriovenous fistulas with a saphenous vein graft. A subclavian surgical approach was used. All reconstructions were performed at least two weeks after the creation of the initial fistula.

RESULTS:

The authors have performed nine reconstructive cases for malignancy using five different free flaps. The subclavian and transerve cervical arteries were used, and the subclavian, internal jugular and cephalic veins were used for microanastomosis. Two cases of flap hematoma and one case of venous pedicle compression were recorded. No cases of flap failure were reported.

CONCLUSIONS:

Reconstruction using temporary arteriovenous fistulas is a reliable technique that can be used in the vessel-depleted neck, with excellent outcomes in experienced hands.     

Distal Revascularisation with Interval Ligation (DRIL): An Experience

INTRODUCTION

The global increase of chronic renal failure has resulted in a growing number of patients on haemodialysis using arteriovenous fistulas (AVFs). By virtue of their very function, AVFs at times shunt blood away from regions distally, resulting in an ischaemic steal syndrome. Distal revascularisation with interval ligation (DRIL) has been described as a procedure to treat symptomatic ischaemic steal. We present our experience in the management of this complication.

PATIENTS AND METHODS

Six patients with severe ischaemic steal were treated using a DRIL procedure between May 2004 and June 2007. There were three males and three females, all with elbow brachiocephalic AVFs. Symptoms ranged from severe rest pain to digital gangrene. Published results from international studies of 135 DRIL procedures were also reviewed.

RESULTS

Vascular access was maintained along with the elimination of ischaemic symptoms in the six patients using an ipsilateral reversed basilic vein graft. Interval ligation of the distal brachial artery was performed at the same time. All patients showed immediate and sustained clinical improvement of symptoms with a demonstrable increase in digital pulse oximetry.

CONCLUSIONS

DRIL is a beneficial treatment option that has proven successful at alleviating ischemic steal symptoms and preserving vascular access. This avoids placement of central lines, its associated risks, and the need to create an alternative sited fistula.