Cryopreserved saphenous vein allografts in infrainguinal revascularization: analysis of 240 grafts

INTRODUCTION: Cryopreserved saphenous vein allografts (Cryograft; CryoLife, Kennesaw, Ga) have been used as conduit in infrainguinal revascularization when autogenous vein is inadequate or unavailable. Although some studies of Cryografts report poor long-term patency, an anticoagulation protocol may improve outcome. We evaluated our experience with Cryografts to further define their role in lower extremity revascularization.Patients and methods Between March 1992 and March 2002, 240 infrainguinal revascularization procedures with Cryografts were performed in 199 limbs of 177 patients. Eighty-nine percent of procedures were performed because of ischemic rest pain or tissue loss, and 75% of vein grafts were implanted into infrapopliteal targets. Most patients received anticoagulation therapy with warfarin sodium or aspirin, or both, postoperatively. Mean age of the cohort was 78 years; 61% were women; 75% had hypertension, 58% had diabetes, and 38% had renal dysfunction; and 47% were current or past smokers. RESULTS: Mean follow-up was 7 months (range, 0-48 months). Primary patency rate was 83% at 1 month, 50% at 6 months, 30% at 12 months, and 18% at 24 months. Diabetes adversely affected graft patency. Warfarin sodium or antiplatelet therapy did not significantly improve graft patency. Limb salvage was 80% at 1 year and 71% at 2 years. CONCLUSIONS: Cryografts have low primary patency rates that are not affected by anticoagulation with warfarin sodium. Short-term patency of these grafts may be sufficient to heal ischemic wounds and thereby prevent limb loss. However, other less expensive alternatives, eg, prosthetic grafts with vein cuffs, are available and appear to have better patency. Accordingly, use of Cryografts should be limited to revascularization through infected fields in patients without autogenous conduit.     

The incidence of thromboembolism in the surgical intensive care unit

The clinical diagnosis of deep venous thrombosis (DVT) is unreliable. Studies have been performed examining the utility of frequent duplex scans. However, these studies included patients outside of the intensive care unit. The incidence of venous thromboembolism and the effect of a less intense surveillance protocol was prospectively examined at a level-1 urban trauma center for a 6 month period. During the study period there were 726 admission to the surgical intensive care unit. Sequential compression devices (SCDs) were used for DVT prophylaxis in 93 per cent of the admissions. A total of 114 duplex scans were ordered: 42 per cent for surveillance and the rest for evaluation of a clinical indication. Twelve DVTs were discovered (11% overall DVT rate). No patient on subcutaneous heparin or low-molecular-weight heparin developed a DVT or pulmonary embolism (PE). Four patients suffered a PE; however, none were found to have a lower extremity DVT on duplex ultrasound and all received SCD prophylaxis. Overall, proper use of DVT prophylaxis for intensive care unit days 1-14 was 77 per cent. The incidence of venous thromboembolism in a group of patients at overall high risk was low. A program of DVT surveillance with duplex ultrasound was not cost-effective.     

Spontaneous reduction of intussusception: clinical spectrum, management and outcome

Background. To analyze the spectrum of clinical features, management and outcome of children with documented spontaneous reduction of intussusception (SROI).¶Materials and methods. Review of records of 50 children (33 boys, ¶17 girls; age range 11 days–15 years; mean age 4 years) with documented SROI, in whom intussusception was initially diagnosed by sonography (US) in 44, air enema in 2, and computed tomography in 4, in the 6-year period 1992–1998.¶Results. Symptoms suggestive of intussusception were present in 21 (3 of whom had Henoch-Schönlein purpura and 4 had previous ileocolic intussusception reduced by air enema). Intussusception was an incidental finding in the other 29, in 28 of whom the finding was in the small bowel. Intussusception was limited to the small bowel in 43 and was ileocolic in 7. SROI was usually documented on US. Laparotomy performed in only 4 showed no evidence of intussusception or pathologic lead point. Outcome in all patients was favorable.¶Conclusions. SROI may present in symptomatic or asymptomatic children and occurs more commonly than previously reported. These intussusceptions are usually short-segment, small-bowel intussusceptions with no recognizable lead point. In asymptomatic patients, conservative observation is warranted. Intervention should be dictated by the clinical findings in symptomatic patients.     

External validation of Vascular Study Group of New England risk predictive model of mortality after elective abdominal aorta aneurysm repair in the Vascular Quality Initiative and comparison against established models

Objective

The purpose of this study is to externally validate a recently reported Vascular Study Group of New England (VSGNE) risk predictive model of postoperative mortality after elective abdominal aortic aneurysm (AAA) repair and to compare its predictive ability across different patients' risk categories and against the established risk predictive models using the Vascular Quality Initiative (VQI) AAA sample.

Delayed retroperitoneal arterial hemorrhage after inferior vena cava (IVC) filter insertion: case report and literature review of caval perforations by IVC filters

Transvenous placement of inferior vena cava (IVC) filters has become commonplace in selected patients with deep venous thrombosis (DVT) and pulmonary embolism (PE). IVC filters have been shown to have excellent therapeutic efficacy and low complication rates. Penetration of the IVC by filter hooks or struts has been reported and commonly noted to be inconsequential. We report a laceration of a lumbar artery by a stainless steel Greenfield (SSG) filter strut that resulted in a near fatal hemorrhage, and review the world literature on caval perforation by IVC filters.     

Dexmedetomidine as sole agent for awake fiberoptic intubation in a patient with local anesthetic allergy

A series of case reports acknowledges the efficacy of dexmedetomidine as a sole sedative for awake intubations in managing a critical airway. However, most case reports documented in the literature used topicalization of the oropharynx either via nebulized lidocaine or the spray-as-you-go technique with either 2% or 4% lidocaine spray to achieve successful intubation. The following case report presents an intensive care unit (ICU) patient with a critical airway who had a true documented allergy to local anesthetics. This case report demonstrates that dexmedetomidine appears to be useful for sedation during awake intubations in critical airways, without the need for airway topicalization. The ability of dexmedetomidine to act as a sedative, anxiolytic, analgesic, and antisialagogue without causing respiratory depression is promising to the field of anesthesiology. Additional studies are needed to elucidate its potential role as the sole agent for awake fiberoptic intubation.     

Endovascular revascularization of symptomatic infrapopliteal arteriosclerotic occlusive disease: comparison of atherectomy and angioplasty

The preferred method for revascularization of symptomatic infrapopliteal arterial occlusive disease (IPAD) has traditionally been open vascular bypass. Endovascular techniques have been increasingly applied to treat tibial disease with mixed results. We evaluated the short-term outcome of percutaneous infrapopliteal intervention and compared the different techniques used. A retrospective analysis of consecutive patients undergoing endovascular treatment for infrapopliteal arterial occlusive lesions between 2003 and 2007 in a tertiary teaching hospital was performed. Patient demographic data, indication for intervention, and periprocedural complications were recorded. Periprocedural and short-term outcomes were measured and compared. Forty-nine infrapopliteal arteries in 35 patients were treated. Twenty vessels (15 patients) underwent angioplasty and 29 vessels (20 patients) were treated with atherectomy. Demographic and angiographic characteristics were similar between the groups. Twenty-six patients had concurrent femoral and/or popliteal artery interventions. Overall, technical success was 90% and similar between angioplasty and atherectomy groups (85% versus 93%, p = NS). The vessel-specific complication rate was 10% and was similar between both groups (angioplasty 5% versus atherectomy 14%, p = NS). One dissection occurred in the angioplasty group; one perforation and three thromboembolic events occurred in the atherectomy group. Limb salvage and freedom from reintervention at 6 months were 81% and 68%, respectively, and were not significantly different between the angioplasty and atherectomy groups. Endovascular intervention for IPAD had acceptable periprocedural and short-term success rates in our high-risk patient population. Both atherectomy and angioplasty can be used successfully to treat symptomatic IPAD.     

Percutaneous mechanical thrombectomy and pharmacologic thrombolysis for renal artery embolism: case report and review of endovascular treatment

Renal artery embolism (RAE) is an uncommon event that is associated with a high rate of renal loss. We present a case of RAE to a solitary kidney that was treated with combined percutaneous rheolytic thrombectomy, intra-arterial thrombolysis, and supplemental renal artery stent placement.