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

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

Evaluation of brachial artery, brachial vena commitante fistula: as an autogenous option for hemodialysis access

The optimal dialysis access for patients with end-stage chronic renal disease is considered to be an autogenous arteriovenous fistula [AVF]. In this case series we describe our experience with an autogenous fistula created using one of the venae commitantes of the brachial artery, evaluating its technical aspects, efficacy and complications. From January 2002 until February 2005, 32 patients were operated on for dialysis access. All patients had no adequate superficial veins either by clinical examination or by ultrasound study. Ultrasound mapping of the basilic vein was done for all cases, suggesting an adequate vein [i.e, diameter>2mm]. On exploration of the basilic vein it was found to be non suitable for creation of a fistula. Instead of using a prosthetic graft, we proceeded with the dissection of one of the venae commitantes of the brachial artery and created brachial artery-brachial vena Commitante fistula .Follow up of the cases for one year was done to scrutinize the fistula for patency and complications. 32 fistulas were done in 32 patients. There were 18 females and 14 males, with mean age of 42.56 year [range 17-62 year]. 25 patients were diabetic. The mean operative time was 85 minutes. Primary failure occurred in 3 cases [3/32, 9.3%]. Postoperative complications included: massive bleeding in one case [1/32, 3.1%], wound infection in 2 cases [2/32, 6.2%] edema of the hand and forearm in 2 cases [2/32, 6.2%] and lymphorrhea in one case [1/32, 3.1%]. 4 cases lost follow up. Remote complications included: thrombosis in 2 cases [2/25, 8%] and vein aneurysm in one case [1/25, 4%]. One year patency rate was 23/25 [92%] after exclusion of cases of primary failure and cases lost follow up. The brachial artery-brachial vena Commitante fistula could be a feasible option for hemodialysis access in patients with no adequate superficial veins and when the basilic vein is not suitable for creation of fistula before resorting to prosthetic graft

outcome of toxic epidermal necrolysis syndrome: revisited

Toxic epidermal necrolysis syndrome [TEN] is an uncommon acute life-threatening blistering disease characterized by involvement of the skin, multiple mucous membranes and internal organs. It is most commonly precipitated by the administration of medication like anticonvulsants. Different variables have been identified as risk factors- The aim of the study was to highlight some variables determining the clinical outcome. This retrospective study included 9 cases diagnosed as toxic epidermal necrolysis syndrome in the period from 2001 to 2005, The case records of all patients were studied in detail regarding the drugs implicated as the cause, the pre-referral period, the body surface area affected, the presence or absence of sepsis, the management and the clinical outcome. The study group was classified according to outcome into survivors and non survivors. Statistical comparison was done with t and x[2] tests, with P value less than 0.05 considered significant. Survivors were 5 patients and non survivors were 4 patients. Anticonvulsants were implicated as the cause of TEN in 4 cases, nonsteroidal anti-inflammatory drugs in 4 cases, and antibiotics in one case. The average time from the onset of symptoms to admission to the burn unit was 2.80 +/- 0.98 days for survivors and 7.13 +/- 1.43 days for nonsurvivors [P = 0.012]. The average body surface area affected was 28.00 +/- 4.35% for survivors versus 34.75 +/- 14.06% for nonsurvivors [P 0.338]. Sepsis was present in 5 cases [4died and one survived]. Pre-referral of patients with toxic epidermal necrolysis syndrome to the burn center affects significantly the clinical outcome, so early referral is recommended