Pulse-spray pharmaco-mechanical thrombolysis for acute proximal deep vein thrombosis

The aim of this study was to evaluate the efficacy, safety, and feasibility of pulse-spray pharmaco-mechanical thrombolysis for treating patients with proximal deep vein thrombosis [DVT]. We studied 24 consecutive patients [14 men, 10 women, with mean age 36 years, range,19-59 years], with acute [less than 15 days] proximal DVT affecting the iliofemoral vein in 18 patients [75%], and/or femoro-popliteal vein in 6 patients [25%]. They were diagnosed by clinical examination, duplex ultrasonography. Contrast venography at the beginning of thrombolysis was done. All were treated with pulse-spray technique, using streptokinase, through the popliteal vein puncture under guidance of duplex scanning. Early success was assessed by comparing the pre- and post-treatment venographic severity score. All patients were discharged at oral Warfarin and followed by duplex scanning for one year. The average total dose of streptokinase was 3.6 million IU [range; 2.55-9.6 million IU] and the average duration of therapy was 2.4 days [range: 1-4 days]. Complete lysis was achieved in 12 patients [50%], partial lysis in 11 patients [45.8%], and suboptimal lysis in only one patient [4.1%]. Adjusted dose of heparin was used in conjunction with thrombolysis. In one case stenotic iliac vein lesion were uncovered after thrombolysis, and another one in the common femoral vein, both treated by balloon dilatation. There was no major treatment-related complication. The use of selective intra-thrombus pulse-spray pharmaco-mechanical thrombolysis was safe and effective approach for treating acute proximal DVT with minimal complications

Comparative study between sapherio-femoral disconnection and low molecular weight heparin in management of above knee great saphenous vein superficial thrombophlebitis

The aim of this work is to assess the safety and efficacy of saphenofemoral disconnection [SFD] in comparison to low molecular weight heparin [LMWH] in cases of above knee great saphenous superficial thrombophlebitis [STP] without involvement of the deep venous system. 40 patients who completed the study period with mean age 37.5 years, were diagnosed as having above knee great saphenous STP without involvement of the deep venous system clinically and with duplex examination. Blood tests for hypercoagulable state was done They were divided into two comparable groups each group was 20 patients: the first group was treated with SFD and the second group was treated with LMWH for 3 weeks [The first week: the recommended therapeutic dose, and prophylactic dose in the remaining two weeks] and following both groups of patients clinically and with duplex at one week, 1, 3, 6, months for complications, -resolution, recurrence and occurrence DVT [Deep Vein Thrombosis]. Minor complications and resolution of the symptoms in the first week were equal in both "' groups but the rate of first month recurrence of STP is higher in surgically treated group [statistically non-significant]. Detection of DVT in follow up period is higher in the first 3 months of follow up in the surgically treated group [statistically non-significant] after that it was the same in both groups where no DVT was observed with either therapeutic method after 3 months to 6 months. Neither pulmonary embolism [PE] nor mortality was recorded in this work. DVT was treated medically. No abnormal blood test for hypercagulable state was found before inclusion or during the study in any patient. STP of the lower limb is easy to diagnose but till now there is no standard management because the etiology is not clear, it shares DVT in some etiological factors but not all factors. Routine survey for thrombophylia is not recommended in the first attack of STP. SFD was stressed as an emergency operation in cases of above knee great saphenous vein [CSV] STP without involvement of ' the deep venous system. In this study it is found that no statistically significant difference between the groups of SFD and LMWH group in aspects of resolution, recurrence, and onset of DVT during the period of the study

Management of arterial trauma of pediatric extremities [a report on 30 patients]

To review the diagnosis and treatment of children with upper and lower extremities arterial injuries and to evaluate the long-term outcome of long emgraft in pediatric aged group. A study of arterial trauma that needed surgery in children less than 13 years of age presented to Tanta University Hospital in the period from February 2001 to October 2005. Thirty [30] children were located who had arterial traumas distributed between lower extremity [20 cases] and upper extremity [10 cases]; exclusion criteria included isolated venous injuries, primary amputations. Clinical examination and duplex scanning were used for every patient at follow-up. Thirty children [24 boys and 6 girls] with an average age of 65 years [range, 3.5-13 years] were reviewed. The mechanisms of injury were blunt trauma in 20 patients [most of them were due to car accidents], penetrating injury in 10 cases. The most commonly injured arteries were 11 femoral, 6 popliteal, 5 brachial. An obvious delay in repair was evident in this series as 70% of cases [21 patients] were admitted to peripheral hospitals before reaching our center. Among 11 femoral injuries: 7 treated by long interposition graft [> 5cm] and 2 by femoropopliteal bypass to below knee segment. The material used for arterial repair were great saphenous vein [GSV] in 7 cases, the superficial femoral vein as an interposition graft in one case, and two parallel strips from contra-lateral GSV sutured together to obtain a wide lumen in another one In the popliteal segment: the use of intraluminal shunt and early fasciotomy to avoid ischemic nerve damage and decrease reperfusion injury, and then reconstruction with reversed saphenous interposition graft. Ligation of the bleeding infected pseudoaneurysm in the posterior tibial [1] and in the dorsalis pedis [1] was done. In the brachial: Three cases needed bypass either anatomical or extra-anatomical, and one in situ cephalic vein bypass, thrombectomy and dilatation through transverse arteriotomy was done in two cases. Saphenous interposition graft was done in 3 cases of the axillary and vein patch angioplasty in subclavian artery injury.. Most children had associated problems related to trauma especially bone fractures and soft tissue lacerations. Mortality rate in this series was 4 cases out of 30 cases [13.3%]. Delayed amputation needed for 3 cases [10%], two above knee amputations and one above elbow. At discharge all patients [22] had good distal pulse and functioning limb except one with brachial plexus injury. All patients advised to take aspocid 75 mg/daily. The patency of small diameter vein graft which was used as: long grafts in the remaining 12 cases, short graft or patch angioplasty in 5 cases were assessed. Only 12 patients completed the follow-up for 3 years. Duplex scanning showed no occlusion, non significant stenosis in two cases, no aneurysmal dilatation. Blunt trauma is more common than other causes in pediatric arterial injuries which masks the early diagnosis and makes the outcome poor. However, an aggressive vascular repair, innovative ideas, and expert vascular surgeon will allow limb salvage even in the presence of diagnostic delay. Invasive diagnostic studies have minimal role in these cases. Surgical repair can be performed in children and autogenous venous conduits are the best suitable bypass materials with patency and freedom from aneurysmal dilatation up to 3 years

Surgical salvage of ruptured arteriovenous fistula for hemodialysis with bleeding

The ruptured arteriovenous fistula [AVF] with bleeding is an emergency situation in end stage renal disease [ESRD] patient who is already anemic patient with co-morbid conditions. Infection, pseudo- aneurysm and complete disruption of anastmotic suture line may be found in these cases. There is no report regarding the surgical salvage of the failed ruptured native AVF with bleeding and the current literature is only about ligation of the AVF. The aim of the work is to report the safety and efficacy of surgical management of bleeding ruptured AVFs by arrest of bleeding and reconstruction of a new one using the same artery and already mature vein at the same situation to maintain the valuable vascular access. This retrospective study involved 16 patients [9 males, 7 females] with mean age 48.5 years with ESRD who presented as emergency bleeding ruptured AVFs during three years time period. In 15 cases there were complete disruption of the of the anastmotic suture line [12 brachio-cephalic, 3 radio- cephalic], and in the middle of one saphenous loop in the thigh. Recreation of the AVFs was done by end to end anastmosis of the proximal part of the healthy artery and mature vein fashioned as smooth U figure in proximal healthy tissues. Diabetes mellitus was the cause of ESRD in 12, systemic lupus erythomatouses [SLE] in 2 and chronic glomerulonephritis in 2 cases. Mean tourniquet time was 13 minutes. No intra-operative blood transfusion was needed. Mean digital Oxygen saturation was 92%. Mean operative time was 50 minutes. Mean duration of hospital admission was 2 days. Post-operative broad spectrum antibiotics were given and after that according to the culture and sensitivity. One patient had nerve concussion due to tourniquet, one patient had secondary hemorrhage after one week and the fistula was ligated and another patient had short fistula in the arm. Mean time of postoperative use of salvaged AVFs in HD [hemodialysis] was one week. No mortality due to the procedure or during the time of the study was recorded. Fourteen AVFs in mean period of follow-up was 18 months [range 3 to 36 months] are functioning. Surgical salvage of the ruptured arterio -venous fistula [AVF] with bleeding even with presence of infection is an effective procedure that achieves many goals: saving the life of the patient, continued primary and secondary patency of the native fistula, avoidance of limb ischemia, avoidance of temporary catheters and their complications, avoidance of creation of new AVF in another site with exhaustion the available veins and waiting for their maturation so, decreasing mortality and morbidity of the patients

Surgical management of non-ischemic diabetic heel ulcers and the role of magnetic resonance imaging [MRI] in these cases

Amputations distal to the heel are minor foot amputations while proximal amputations to the heel are major. Heel ulcers may be superficial but may send infection deep to bone [calcaneus] and/or-Achilles tendon .In the start of the treatment the anticipated outcome is not well known. The Aim of the work is to report our results of management of chronic non-ischemic diabetic heel ulcers including: surgical management in the form of debridement, partial calcnectomy and partial excision of Achilles tendon plus off-loading, edema management and wound management. Role of medical management of diabetes mellitus [DM] and comorbid conditions and to report the role of MRI in diagnosis and management these cases. This retrospective study involved Sixty patients [33 female, and 27 male], mean age 55.87 [range 26-78 years, mode 60 years] with 66 heel ulcers in the 4 year period from January 2002 to January 2006. Diagnosis of neuropathy and vascular state were done. Photographic documentation of the ulcers, Plain-x-ray and MRI were used to diagnose osteomyelitis. In twelve cases partial calcanectomy and in 5 Achilles tendon was partially excised. Regular debridement, wound care and control, management of infection, hyperglycemia, comorbid conditions was performed in all patients plus post-operative off-loading, patient and relatives education. Follow up of the patients. End points of the study were ambulation and independency of the patient, healing of the ulcers, proximal amputation, or death of the patient. All of the Ulcers were >2 cm[2] surface area with duration > 8 weeks. Most of them were in the right side in the planter aspect. MRI showed osteomyelitis in 12 cases of the calcaneus and they were managed by partial calcanectomy. Foot stability and patient independence was achieved after partial excision of Achilles tendon. Complete healing of the ulcers after one year of management was in 68% of the ulcers. Blow knee amputations were done in 5 cases and above knee in two. Seven patients died within 4 year period due to metabolic, cardiac and cerebral causes. Multidisciplinary approach including vascular surgery, radiological imaging and internal medicine is crucial to successful treatment through integration of knowledge and experience. Debridement of chronic or infected tissues even if Achilles tendon or calcanei are involved is essential for ulcer healing. MRI has a role in accurate detection of precise area of osteomyelitis allowing proper debridement and partial calcanectomy with little morbidity and major impact on patient and limb outcome