Short term outcome of brachial plexus block in vascular access surgery

To present short term outcome of brachial plexus block for upper limb vascular access procedures performed for renal dialysis. This is a retrospective review of all cases that had a brachial plexus block for a renal dialysis vascular access procedure at the vascular surgery unit in King Hussein Medical Center, Amman, Jordan, between January 2009 and September 2011. Two hundred eighty- eight patients [172 males, 116 females] with a mean age of 41 [19-68] years had the block. In 183 [63.5%] patients the procedure was primary and in 75 [26.0%] patients it was native access. Procedures performed included: 27 [9.4%] brachio-cephalic arteriovenous fistula, 48 [16.7%] basilic vein transposition, 96 [33.3%] forearm prosthetic loop graft, 67 [23.3%] upper arm prosthetic loop graft, 25 [8.7%] salvage procedures with interposition prosthetic grafts, 14 [4.9%] removal of infected prosthetic grafts, and 11 [3.8%] repairs of false aneurysms and disrupted anastomoses. All blocks were guided by a nerve stimulator at strength of 0.2-0.5MHZ and Bupivacaine 0.375 [25-35 ml] used for the block. Supraclavicular block was used in 132 [45.8%] patients while combined supraclavicular and axillary blocks were used in 156 [54.2%] patients. When local anesthetic infiltration was needed for supplementation of the block, Lignocaine 1% [10-15 ml] was used. Data regarding the procedure, adequacy of the block, time of onset, duration of block, and immediate complications was retrospectively collected from anesthetic charts and operative records. All patients had an adequate block with no conversions to general anesthesia or cancellation of the procedure. A successful block was achieved in 232 [80.6%] patients while a partially successful block was achieved in 56 [19.4%] patients. The median time for onset of the block was 10 [5-20] minutes for motor block and 15 [10-35] minutes for sensory block. The mean duration of the block was 5.6 [2.2-48.0] hours. Prolonged blocks beyond 24 hours occurred in 5 patients [48 hours in 1 patient, 36 hours in 1 patient, and 24 hours in 3 patients]. Injection related complications included discomfort during injection in 100 [34.7%] patients and local hematomas relieved by compression in 8 [2.8%] patients]. Transient nerve paralysis complicated 82 [28.5%] cases [phrenic nerve in 57 [19.8%] patients, sympathetic chain resulting in Horner's syndrome in 20 [6.9%] patients and vagus nerve resulting in hoarseness of voice in 5 [1.7%] patients]. No clinically detectable pneumothorax or drug toxicity occurred. No peri-operative mortality was reported during the study period. Brachial plexus block is an effective and safe mode of anesthesia for upper limb renal dialysis vascular access procedures. It offers major advantages over general anesthesia and enjoys low rate of failure and complications. Its use as a main mode of anesthesia for such procedures is advisable

Result of supra-genicular femoropoliteal bypass done for critical limb ischemia

To report our experience with supra-genicular femoropopliteal bypass performed for critical limb ischemia. This is a retrospective review of supra-genicular femoropopliteal bypass were performed at our vascular surgery unit in King Hussein Medical Center, Amman, Jordan, between March 2008 and March 2010. Sixty three patients [49 male, 14 female] had 67 procedures [bilateral in 4 patients]. Fifty seven procedures done in 53 patients for critical limb ischemia were followed up for twelve months. During this period eight patients were lost to follow-up and were also excluded from the analysis. Records of the remaining 45 patients [35 male, 10 female] with 49 procedures were analyzed for operative details, patient risk factors, primary patency rates, complications, limb salvage rates. The surgical technique was uniform. Follow-up was clinical and by duplex scanning at six weeks, three and six months, and one year. Graft patency was considered terminated if the patient had an occluded graft or needed further procedures to keep the graft patent. In 31 [63.3%] limbs the indication for the procedure was tissue loss, while in 18 [36.7%] it was rest pain. The primary end point was primary graft patency calculated as 69.4% [reversed long saphenous vein 83.3%, prosthetic 61.3%]. The limb salvage rate was 83.7% [reversed long saphenous vein 88.9%, prosthetic 80.6%]. Five major limb amputations were done for non-healing wounds and three for prosthetic graft infections. Procedure related complications included surgical wound problems,[5] and nerve injuries.[4] The most ominous complication was prosthetic graft infection as three out of four resulted in graft occlusion and removal and eventual limb loss while one was replaced by saphenous vein. Perioperative 30 day mortality was two [3.8%] patients while another six [11.3%] died during the one year follow up period. Supra-genicular femoropopliteal bypass performed for critical ischemia has an acceptable patency rate at one year and is an effective mean of limb salvage. Prosthetic graft infections are a main cause of limb loss. The use of vein conduits should be aggressively pursued

Report of regional single center experience of endovascular abdominal aortic aneurysm repair at King Hussein medical center

To present our experience with elective Endovascular Aneurysm Repair [EVAR] cases done at King Hussein Medical Center, Amman, Jordan. This is a retrospective chart review of elective Endovascular Aneurysm Repair procedures done during the period of January 2004 to November 2010. One hundred seventeen patients [91 males and 26 females] with a median age of 71 [range 52 to 79] successfully underwent the procedure. Devices used included Endurant [Medtronic AVE, Santa Rosa, Calif], Zenith [Cook Inc, Bloomington, Ind], Talent [Medtronic], and Excluder [W.L. Gore, Flagstaff, Ariz]. Configurations included, 113 [96.6%] aorto-bi-iliac, three [2.6%] aorto-uni-iliac with femoro-femoral crossover graft, and one [0.8%]straight tube graft. Most patients [n=85, 72.6%] scored 3/4 in the American Society of Anesthesia [ASA] scale and had significant comorbidities. CT angiography was the main imaging modality used in both preplanning stage and follow up. Primary outcome measures included overall mortality and freedom from aneurysm rupture. Secondary outcome measures included access site complications, graft limb complications, and endoleaks. No conversions to open surgical repair or ruptures occurred post graft implantation. A total of 14 [12.0%] patients underwent re-intervention most of which were for access site problems. These included wound hematoma treated conservatively [n=5, 4.3%], wound infection treated with drainage and antibiotics [n=3, 2.6%], and vessel dissection or occlusion needing surgical repair [n=2, 1.7%].Graft limb complications included occlusions needing femoro-femoral bypass [n=2, 1.7%]. A total of 27 [23.0%] endoleaks were diagnosed: three [2.6%] were type I and were managed with ballooning and proximal extension in one case, 1[0.9%] type 3 managed with an iliac limb extension, and 23 [19.7%] type 2 endoleaks managed conservatively. The mean in hospital length of stay [LOS] was 3.1 days [range 2-7] while the mean follow up was 16.2 months [range 6-58]. Overall patient mortality during the study period was eight [6.8%] patients while in hospital mortality was four [3.4%]. All late deaths were aneurysm unrelated. Endovascular Aneurysm Repair is technically feasible and effective in aneurysm exclusion and preventing rupture. It offers major advantages over open aneurysm repair including reduced early mortality, hospital stay, and use of intensive care facilities. However, issues of cost effectiveness and late mortality in our setting are still to be resolved

Familial popliteal artery entrapment syndrome: a case report

A 27-year-old male patient was self-referred to the vascular unit at Queen Alia Military Hospital with four years history of intermittent claudication in his left calf. Investigations revealed familial popliteal artery entrapment syndrome. He was treated surgery ieally followed by smooth post-operative follow up