Pediatric vascular trauma: diagnosis management, and outcome

Although vascular injury is relatively infrequent, it contributes to significant morbidity and mortality. Because pediatric vascular injury is not uncommon during childhood and adolescence, surgical management has traditionally been based on adult trauma experience. This report examines the causes, mechanisms of injury, associated trauma, and results of treatment of pediatric patients with vascular injuries. Fifteen children with 13 arterial and 2 venous injuries were included in the study. There were 9 boys and 6 girls with a mean age of 63 months [range; 1day-13 years]. Sixty percent of children were in preschool age [6 years]. The mechanism of injury was penetrating trauma in 6 patients, blunt trauma in 4, and iatrogenic trauma in 5. Vascular injuries were divided between the upper extremity [7], lower extremity [6], neck [1], and abdomen [1]. Open surgery was the method of treatment in 12 children, Medical treatment consisting of systemic heparin administration was offered in 3 children. Vascular repair was attempted in 5 preschool and in 4 older children. The vessels were ligated in 3 children. There were 3 deaths, all of which occurred in the nonoperative group due to other causes. One patient, in the surgical arm, underwent a below-knee amputation. Overall, the outcome was good in 73.3% [11/15] cases [9 1.7% among surviving patients]. The results of the present study allow us to conclude that an aggressive approach, with early intervention and reconstructive techniques, allows successful management of most of pediatric vascular injuries

Combined iliac artery angioplasty and infrainguinal reconstruction in multilevel atherosclerotic disease

Patients with limb ischemia and diffuse aortoiliac or combined aortoiliac and femoropopliteal disease present as a difficult problem for surgeons. Is to present our early experience with the combined use of iliac artery angioplasty and infrainguinal surgical revascularization for the treatment of multilevel artherosclerotic disease. Thirteen patients with iliac artery stenosis and femoropopliteal occlusive disease were treated with fem-pop grafting and iliac balloon angioplasty [IBA] which was performed percutaneously within 1-2 days before surgery. Stenting was performed for suboptimal IBA. Graft patency was evaluated by clinical examination, duplex scanning/ankle-brachial index [[ABI] at 1, 3, 6, and 12 months. indications for surgery were limb salvage [46%], rest pain [23%], and claudication [31%]. IBA alone was successful in 10 patients. Stenting was needed in the remaining 3 patients. Distal bypass grafting was performed with an autogenous vein conduit in 10 patients. PTFE placed in the above-knee popliteal segment was used in 3 patients. The primary patency of combined procedures at 1year was 81.8%. There was only one amputation with an overall limb salvage rate of 90.9%. Iliac angioplasy can successfully be used as a prelude to distal arterial bypass in patients with multilevel atherosclerotic disease

Raised plasma homocysteine as a risk factor for idiopathic and recurrent deep-vein thrombosis

Previous studies have suggested that hyperhomocysteinemia [Hyper-Hcy] may be a risk factor for venous thrombosis. To assess the risk of venous thrombosis-associated with Hyper-Hcy, we studied plasma total homocysteine [tHcy] levels in patients with deep venous thrombosis and in normal control subjects. Fasting tHcy levels were measured in 40 consecutive patients with objectively diagnosed deep venous thrombosis and in 20 healthy controls matched to the patients according to age and sex. Hyper-Hcy was defined as plasma total homocysteine level > 15 micro mol/l. Plasma homocysteine level was significantly higher in patients than in controls. It was significantly higher in patients with idiopathic [unprovoked] vein thrombosis than in patients with secondary disease [associated with at least one predisposing factor]. Mean homocysteing was higher in male than in female patients and increased with age. Hyperhomocysteinemia was more frequent in patients with relapsing disease than in those presenting with a single episode. Mean homoqsteine level was similar in patients presenting with either proximal or calf vein thrombosis. Mild Hyper-Hcy is an independent risk factor for deep- vein thrombosis, more prevalent in patients with idiopathic or recurrent disease. The next question to be answered is whether homocysteine-lowering therapy - folic acid, vitamin 36 or vitamin B12 contributes to the prevention of recurrent venous thrombosis

Hemodynamic assessement of surgically created arteriovenous fistula for hemodialysis

Fifty patients with chronic renal failure were involved in this study. A radiocephalic fistula of the Brescia-Cimino type was newly created for hemodialysis in 45 patients. Nine of these 45 patients, showed an immediate fistula failure. Several hemodynamic parameters were found to be of important prognostic values to ensure a successful fistula outcome with a flow rate of >200 ml/min. A preoperative subclavien vein flow of >300 ml/min. and an arterial inflow of >/40 ml/min. were associated with a high fistula success rate. Besides, a postoperative decrease in resistively index [RI] of the inflow artery of >/0.1 resulted in a 100% success rate. Flow measurements were done by utilizing color flow duplex imaging. Therefore, the use of duplex imaging is beneficial during the evaluation of patients, who are candidates for an arteriovenous fistula operation. The remaining five patients had an already cerated arteriovenous fistula. They were studied with high output fistulas. This category of patients underwent banding correction of the existing fistulas. The banding technique resulted in reduction of fistula flow rates by a mean value of more than 60%