Iliac-enteric fistula following Dacron patch angioplasty

We report a patient who developed fistulization between the jejunum and a Dacron patch placed at the bifurcation of the right common iliac artery during endarterectomy 14 years previously. The patient was successfully managed by resection of the iliac bifurcation and a segment of the involved bowel. While arterio-enteric fistulae typically involve prosthetic grafts, they may occur in association with artificial materials used to patch endarterectomy sites; hence, knowledge of technical detail is important in the diagnosis of this complication following endarterectomy. (Ann Vasc Surg     

111Indium is an unreliable in vivo label for vascular endothelial cells

We studied the retention of ¹¹¹Indium-labeled canine endothelial cells on 32 grafts (16 dogs). Canine endothelial cells were harvested from the external jugular veins, grown in culture, and labeled with¹¹¹Indium oxine; 10⁶ factor VIII positive cells were inoculated on fibronectin-coated, 4 mmlD Hytrel grafts and cultured 18 hours to reach confluence. An autologous seeded graft was interposed in each of the common carotid arteries and exposed to flow for six hours.¹¹¹Indium label was measured pre- and postperfusion and corrected for decay. Twenty-five grafts from 13 dogs were available for study. Scanning electron microscopic planimetry was used to determine percent surface coverage by six mutually exclusive surface characteristics: endothelial cells, bare graft, white blood cells on graft, white blood cellson endothelium, white blood cells under endothelium, and thrombus. ¹¹¹Indium retention was compared with percent coverage by scanning electron microscopy using regression analysis.¹¹¹Indium labeling projected an erroneous retention of 41% at zero percent coverage (r=0.67; p<0.01). Multiple regression analysis revealed an equivalent distribution of¹¹¹Indium label over nonendothelial portions of the flow surface and indicated a leak rate into the circulation of 25.6% of the initial¹¹¹Indium label over six hours. We conclude that: 1)¹¹¹Indium labeling data usually overestimates endothelial cell retention; 2) an average of 4.67%/hour is lost into the general circulation; 3)¹¹¹Indium label can be found equally on surfaces of thrombus, white blood cells, and hydrophilic Hytrel graft; and 4)¹¹¹Indium labeling is not a reliable method forin vivo studies of endothelial cell retention.     

Angioscopic assessment of fibrinolysis for impending in situ saphenous vein graft thrombosis

A failing femorotibial in situ saphenous vein bypass graft was found by angioscopic examination to be lined with white thrombus and was successfully treated by intraoperative lytic therapy rather than by thrombectomy with a balloon catheter. The platelet-fibrin debris was completely cleared by 250,000 units of urokinase. There were no bleeding complications and the potential for mechanical damage to the venous endothelium was prevented. The in vivo angioscopic observations of fibrinolysis are described.     

Does division of the left renal vein during aortic surgery adversely affect renal function?

Between July 1980 and July 1988, 478 consecutive patients underwent aortic aneurysm operations at Royal Prince Alfred Hospital. Renal function was assessed by measurement of serum creatinine levels. The left renal vein was divided in 28 (8%) of the 355 patients undergoing elective aneurysm resection. The mean immediate postoperative creatinine values were significantly higher after left renal vein division, 193±174 mol/L, compared to 133±93 mol/l for those whose left renal vein remained intact (p < 0.05 by Mann-Whitney U test). After one month, serum creatinine levels had decreased but were still significantly higher in those patients in whom the left renal vein had been divided, 170±166 mol/l, compared to those in whom it was left intact 109±49 mol/l (p<0.05 by Mann-Whitney U test). The suprarenal aorta was cross-clamped in seven (25%) of the 28 patients in whom the left renal vein was divided, compared to 21 (6%) of the 327 with the left renal vein intact. A rise in creatinine level was observed after suprarenal aortic cross-clamping. The left renal vein was divided in 17 (14%) of the 123 patients having emergency surgery for ruptured aortic aneurysm, 61 (49%) of whom survived more than 30 days. The mean immediate postoperative creatinine values were significantly higher after left renal vein division, 426±277 mol/l, compared to those in whom the vein was left intact, 178±136 mol/l (p < 0.05 by Mann-Whitney U test). After one month, serum creatinine levels were still significantly higher in those patients in whom the left renal vein had been divided. Although division of the left renal vein is a useful way to improve exposure of the juxtarenal aorta, the maneuver is associated with an adverse effect on renal function.Presented at the Annual Meeting of the Peripheral Vascular Surgical Society, New York, New York, June, 1989.     

The peripheral vascular consequences of smoking

Cigarette smoking is associated with an increased risk and extent of advanced atherosclerotic vascular disease in peripheral as well as coronary arteries. The likelihood of claudication, amputation, stroke, abdominal aortic aneurysm, and failure of vascular reconstruction is higher in smokers than nonsmokers. Smoking exerts its deleterious effects through many interactive mechanisms. Nicotine and carbon monoxide produce acute cardiovascular consequences, including altered myocardial performance, tachycardia, hypertension, and vasoconstriction. Smoking injures blood vessel walls by damaging endothelial cells, thus increasing permeability to lipids and other blood components. Among metabolic and biochemical changes induced by smoking are elevated plasma, free fatty acids, elevated vasopressin, and a thrombogenic balance of prostacyclin and thromboxane A ₂.Chronic smoking is associated with a tendency for increased serum cholesterol, reduced high density lipoprotein, and other lipid effects that contribute to atherosclerosis. In addition to rheologic and hematologic changes from increased erythrocytes, leukocytes, and fibrinogen, smokers have alterations in platelet aggregation and survival that produce thrombosis. Considering the ubiquitous repercussions of this menace, vascular surgeons should play an active role in motivating their patients to quit smoking.     

Intraoperative ultrasonography for location of proximal limit of inferior vena caval thrombosis

Appropriate surgical management of inferior vena caval thrombosis is dependent on the proximal limit of the thrombus. Cavograms, computed tomography, or magnetic resonance imaging all have their shortcomings in locating this limit. Intraoperative ultrasonography has allowed us to determine the exact proximal limit of vena caval thrombosis in two patients, one with suprarenal thrombosis, the other with infrarenal thrombosis. In the first patient, caval interruption and clearance of the inferior vena cava was greatly enhanced by the use of this method. Intraoperative sonography is useful in the surgical treatment of thrombosis of the inferior vena cava. (Ann Vasc Surg     

Aortic pseudoaneurysm secondary to celiac plexus block

Traumatic pseudoaneurysm of the abdominal aorta has been infrequently reported in the literature. We report a case of an infected pseudoaneurysm of the supraceliac aorta which we believe to be secondary to celiac plexus block performed for pain from chronic pancreatitis. The aneurysm was successfully repaired using a Dacron graft through a thoracoabdominal approach. The possible mechanism of aortic injury from celiac plexus block is discussed.     

Thoracic aortic ectasia in a patient with Takayasu's disease

Arterial aneurysm formation occurs in 15 to 20% of patients with Takayasu's disease. The timing of surgical intervention of these aneurysms is controversial. A case of ectasia of the descending thoracic aorta in a patient with Takayasu's disease is presented. The diagnosis and timing of surgical intervention of aneurysms associated with Takayasu's disease are discussed.Presented at the Society for Clinical Vascular Surgery Symposium, April, 1991, Kauai, Hawaii.     

Prevention of vascular graft infection by rifampin bonding to a gelatin-sealed dacron graft

This study examines the efficacy of rifampin bonding to a gelatin-sealed knitted Dacron graft to prevent perioperative bacteremic vascular graft infection. Antibiotic bonding was obtained by soaking grafts for 15 minutes in a 1 mg/ml saline solution of rifampin at 37°C. Nineteen dogs had thoracoabdominal aortic bypass: seven (group I) received a rifampin treated graft; six (group II) received an untreated gelatin-coated graft; and six (group III) received an uncoated Dacron graft. Two days later bacteremic challenge was produced by rapid intravenous injection of 5×10 ⁵ colony forming units of methicillin resistantStaphylococcus aureus.Grafts were harvested five days after this challenge and cut into 10 fragments, each submitted to bacterial counts. Results were expressed as CFU/cm ² of graft material. In group I, no graft was infected, whereas all grafts in groups II and III were infected (p<0.05). Median bacterial counts from the infected fragments (median±SD) were similar in groups II (2.5×10⁵ CFU/cm²) and III (4×10⁴ CFU/cm²). Blood cultures at time of sacrifice were negative in all dogs in group I and positive in five of six dogs in groups II and III. Cultures of liver, spleen, kidney, and lung specimens were always negative in group I and positive in 22 of 24 specimens in group II and 23 of 24 specimens in group III. Soaking a gelatin-sealed Dacron graft in rifampin solution evidently prevents early bacteremic graft infection and secondary foci of infection in this model.Presented at the Annual Meeting of the French Vascular Surgery Society, Nancy, France, May 18–19, 1990.     

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.     

Simultaneous resection of renal carcinoma and abdominal aortic aneurysm

A 62-year-old man with a 6.5 cm abdominal aortic aneurysm and coexistent left renal cell carcinoma was treated by simultaneous radical left nephrectomy and abdominal aortic aneurysm repair. Care was taken to avoid potential infection of the bypass graft by inadvertent contamination with urine. Pathologic examination of the left kidney revealed a renal cell carcinoma, clear cell type, with no evidence of invasion into the renal vein or lymph node metastases. The patient had an uncomplicated recovery and is well and free of disease four years after operation. In cases of equivalently life threatening surgical diseases, simultaneous resection is warranted.     

Persistent proatlantal artery associated with carotid artery stenosis treatment by percutaneous transluminal balloon angioplasty

A 58-year-old man had an asymptomatic tight stenosis of the internal carotid artery associated with a persistent proatlantal artery. This as well as other compositional arterial anomalies of the basilar artery were discovered on arteriograms. The stenosis was successfully treated by percutaneous transluminal balloon angiopfasty. Therapeutic choices are discussed in this setting because of the risk of carotid clamping in the presence of persistent carotid-basilar anastomoses. kg]Key wordsPresented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, May 18–19, 1990, Nancy, France.     

Effect of perigraft seroma fluid on fibroblast proliferation in vitro

Different theories have been postulated in the last 10 years in an attempt to explain the pathogenetic mechanisms involved in perigraft seroma formation. This paper reports our experience with in vitro analysis of the cellular composition and the effect of perigraft seroma fluid on fibroblast proliferative activity. Our results indicate that the cellular component of the fluid was almost exclusively represented by polymor-phonuclear leukocytes. Perigraft seroma fluid was stimulatory on fibroblast growth, while plasma samples from the patient and normal controls were inhibitory. These findings suggest that a perigraft seroma may represent a complex phenomenon which cannot be explained exclusively in terms of fibroblast stimulation or inhibition. This pattern displays a close similarity to experimental observations in the early phases of wound healing. Perigraft seroma formation could be mediated by an intense and persistent chemotactic stimulus on leukocytes, which does not allow normal progression of wound healing through fibroblast growth and collagen deposition.     

The assessment of P-wave dispersion and myocardial repolarization parameters in patients with chronic kidney disease

Objective: The risks of sudden death and cardiac arrhythmia are increased in patients with chronic kidney disease (CKD). Here, we aimed to evaluate the indicators of arrhythmias, such as p-wave dispersion (P-WD), QTc dispersion, Tp-e and Tp-e/QT ratio in patients with CKD stages 3–5 on no renal replacement therapy (RRT).

Material and methods: One-hundred and thirty three patients with CKD stages 3–5 and 32 healthy controls were enrolled into the study. No patients received RRT. QTc dispersion, P-WD and Tp-e interval were measured using electrocardiogram and Tp-e/QT ratio was also calculated.

Results: Mean age rates were found similar in patients and controls (60.8?±?14.2 and 61?±?12.9?y, p?=?.937, respectively). Compared patients with controls, P-WD (45.85?±?12.42 vs. 21.17?±?6.6?msec, p?p?p?p?p?p?=?.001) were found to be different. QTc-max and Tp-e interval were found to be similar in both groups.

Conclusion: P-WD and QTc dispersion, Tp-e interval and Tp-e/QTc ratio were found to be increased in with CKD stages 3–5 on no RRT.     

Arterial-ureteral fistula: Case study with review of published reports

Arterial-ureteral fistula, a rare cause of gross hematuria, may be associated with life-threatening hemorrhage if not rapidly diagnosed and treated. Recently, a patient at the Hunter H. McGuire Veterans Administration Medical Center developed an arterial-ureteral fistula at the site of the confluence of the external iliac artery and a superior mesenteric artery bypass graft. Review of the world's literature revealed 31 additional reported cases of arterial-ureteral fistulas [1—31]. This current case is only the second one reported in which the diagnosis was made with arteriography. Several common features of arterial-ureteral fistulas were present in this case: a history of ureteral obstruction and urinary tract infections, upper urinary tract disease, and previous vascular surgery. The condition is usually associated with either prior upper urinary tract instrumentation or vascular surgery, and an antecedent period of intermittent hematuria, followed by life-threatening hematuria, is common. A high index of suspicion and early surgical intervention are required for successful management. The major surgical challenges are to establish unobstructed urinary drainage and restore vascular continuity. Exclusion of prosthetic material from potentially infected areas is mandatory.     

Wound instillation for postoperative pain relief: A comparison between bupivacaine and saline in patients undergoing aortic surgery

In a double blind trial 72 patients having elective aortic surgery were randomized to receive either 40 ml of 0.25% bupivacaine or 40 ml of saline through one or two indwelling wound irrigation catheters every four hours over a total of 48 hours. In transverse incisions the two catheters were randomly placed either subcutaneously or in the rectus sheath; in vertical incisions one catheter was placed subcutaneously. Analgesia was assessed by visual analogue score on Postoperative Days 1 and 2 and the number of doses of intramuscular morphine given during the instillation period. Pulmonary function was monitored by forced expiratory volume and peak flow on Postoperative Days 1 to 5; arterial blood gases were monitored preoperatively and Postoperative Day 2. In all parameters evaluated there was no statistically significant difference between the saline (n=33) or the bupivacaine (n=37) groups. Site of the catheter in the transverse groups made no difference. Comparing vertical (n=21) and transverse (n=49) incisions, the mean visual analogue scores on the first postoperative day were 40 and 29, respectively (p<0.05). Wound instillation with bupivacaine neither improves pulmonary function nor reduces morphine requirements when compared to saline. Transverse incisions may be less painful than vertical ones.     

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.     

Hyperparathyroidism presenting as an unusual cause of lower extremity gangrene

Vascular surgeons are often consulted on the management of lower extremity ulcerations and gangrene which are commonly due to atherosclerotic arterial occlusive disease or to chronic venous insufficiency. The following report describes an unusual case of severe lower extremity cutaneous gangrene associated with secondary hyperparathyroidism and a review of the literature.     

Reconstructive internal carotid artery surgery over forty years (October 20, 1951–1991)

The background and history of internal carotid reconstruction are presented. Highlights in the early development of this technique include the research of John Ramsay Hunt, Moniz, and Leriche, and the surgical techniques of Carrel and Guthrie. Miller Fisher published his extensive studies on cerebrovascular disease and carotid occlusion in 1951. Pioneering operations by Carrea and Molins in Argentina, Strully, Hurwitt, and Blankenberg in New York and DeBakey in Houston soon followed. DeBakey's technique became the standard technique for the surgical treatment of occlusive carotid lesions. Eastcott, Pickering and Rob published the first paper describing a carotid reconstruction inThe Lancet in 1954. Recently two large multicenter trials have reinforced the benefit of carotid surgery under proper indications and in experienced hands.     

Ischemia/reperfusion injury in skeletal muscle

Ischemia reperfusion injury to skeletal muscle may be explained by a cascade of cellular and systemic events initiated by an ischemic period followed by reperfusion. During the period of ischemia there is a gradual reduction of intracellular energy stores. Adenosine triphosphate is gradually depleted despite the buffering effect of creatine phosphate which is present in large stores in muscles. As well, glycogen stores are depleted with resultant production of small amounts of energy and large accumulations of lactate. Upon reperfusion there is a reactive hyperemia, resulting in an overall increase in muscle blood flow, despite the fact that areas may continue to be underperfused. Results of this blood flow are mixed with the beneficial effects of removing metabolic by-products and supplying exogenous substrates and oxygen. However, this blood flow also causes harmful effects by washing out necessary precursors for adenine nucleotide resynthesis. Production of oxygen free radicals occurs with resultant membrane lipid peroxidation, and calcium influx occurs upon reoxygenation with resultant disruption of oxidative rephosphorylation in the mitochondria. The sequestration of white blood cells in the muscle due to up regulation of both neutrophil receptors and endothelial leukocyte adhesion molecules results in a prolongation of the reperfusion injury. This subsequently results in damage to remote organs, including lung, heart, and kidneys. The future for therapeutic interventions aimed at reducing this injury lie mostly in the ability to modulate the reperfusion effect.