Acute Arterial Thrombosis in Leg Associated with Hyperhomocysteinemia

Herein, two cases of acute arterial thrombosis associated with hyperhomocysteinemia are reported. A 34-year old male patient without heart disease, was brought to hospital with an acute ischemic limb due to thromboses of both superficial femoral arteries, where no atherosclerotic lesions were found. Subsequent investigation revealed that the patient had hyperhomocysteinemia, with a low folic acid level. Catheter directed thrombolysis was attempted, but failed, so bypass surgery was performed. After revascularization, anticoagulation therapy and folate supplementation were initiated. His plasma homocysteine level returned to normal, and there has been no recurrence during the 48 month follow up periods. The other case was a 51-year man with an acute left ilio-femoro-popliteal artery occlusion, who had also shown hyperhomocysteinemia, with a low folic acid level. There was nothing abnormal from his medical records, and showed normal findings in his transesophageal echocardiogram. In a serologic hypercoagulability test, everything was normal, with the exception of an increased homocysteine level. After a successful thrombectomy with a Fogarty catheter, folate supplementation was administered until his homocysteine level returned to normal. In both patients, the heterozygous mutation of 5, 10-methylenetetrahydrofolate reductase (MTHFR), C677T (alanine to valine substitution), was detected.

Clinical Results of Lower Extremity Trauma Accompanied with Popliteal Artery Injury

PURPOSE: Although popliteal artery injuries are uncommon, the consequent lack of management protocols may contribute to the high level of outcome morbidity. METHOD: We retrospectively reviewed the records of popliteal artery trauma treated at our institution in the past 5 years. RESULT: In 15 patients [male 13, female 2, median age 45.9 (15-73)] there were 13 cases of blunt trauma, mainly motorcycle accident. Most patients presented with severe signs of ischemia when they arrived at the emergency unit. Most commonly skeletal injury was accompanied (fracture 13, nerve injury 7). Some delays occurred between injury and treatment in every cases. Bypass using the contralateral long saphenous vein was the predominant procedure for arterial injury. Our limb salvage rate was 66.7% (10/15), but all patients needed more than two additive operations, and finally had persistent neurologic disability. CONCLUSION: Popliteal artery injury, especially in Korean urban society, was mainly caused by blunt trauma from traffic accidents and the results remain challenging.

Multi Detector Row Computed Tomography Angiogram as the Sole Preoperative Imaging for Infrainguinal Arterial Surgery

PURPOSE: To assess the suitability of multidetector row CT angiogram (MDCTA) as the sole preoperative imaging for infrainguinal arterial surgery. METHOD: From March 2002 to September 2003, 75 patients (24 claudicants, 41 limb-threatening ischemia) were studied with MDCTA preoperatively. We compared the surgical inflow and outflow site changes between preoperative planning based on MDCTA and the results of final operation. MDCTA was interpreted by the same vascular surgeon, and arterial segments from the renal artery to foot were reviewed. Surgery plans were formulated based on arterial anatomic and hemodynamic characteristics. Additional diagnostic value and test related complications were also studied. RESULT: Twenty- one patients had conventional angiogram after MDCTA scan - 9 for interventional treatment at inflow site and 12 patients for complement of MDCTA, although the operation plan was not changed. The agreement between preoperative plan based on MDCTA and final operation was 100% even in critical limb ischemia. In 11 patients tortuous calcified iliac artery was ambiguous in routine image but it could be solved using the other specific functional option of MDCTA. There were no serious complications related to the test. CONCLUSION: These findings suggest that MDCTA is an adequate preoperative imaging study of infrainguinal arterial surgery and that it may be substituted for conventional angiogram without any serious complication. The particular functional options of MDCTA help resolve its defect.

Pulmonary Embolism Related with Catheter Directed Thrombolysis in Acute Deep Vein Thrombosis

PURPOSE: Catheter directed thrombolytic dissolution (CDT) of deep vein thrombus (DVT) is in widespread use, yet the complications especially pulmonary embolism (PE), associated with the procedure remains ill defined. To assess the incidence of PE we reviewed the clinical course of acute DVT patients treated by CDT. METHOD: From January 2000 to September 2003, 25 patients were treated by CDT. To define the new development of PE, patients had a technetium 99m lung scan before and just after CDT-, and clinical symptoms were recorded. All patients underwent ascending venogram and CT scan initially to define DVT extension. CDT with urokinase was done by a the same intervention radiologist. RESULT: Proximal thrombus extension level was the femoral vein in 8 patients, iliac vein in 12-, and inferior vena cava (IVC) in 5. Complete thrombolysis was achieved in 16 patients, partial lysis in 2 and no lysis in 7. PE was detected in 7 patients with initial lung scan whose thrombus proximal level was IVC 2, iliac vein 4, femoral vein 1 in each, and no changes in lung scan after CDT. In 17 patients with normal findings at intial lung scan, there were also no changes after CDT. One patient with normal lung scan showed high probable scan defects in lung scan after CDT. Because he also complained of sudden onset dyspnea with cough, we diagnosed him as newly developed, PE-related CDT. CONCLUSION: Only one (4%) case of PE was developed in our study. No prediction factor of PE such as CDT results, or thrombus proximal extent could be defined. These findings suggest that routine usage of temporary IVC filter is unnecessary during CDT.

Endovascular Management of Iliac Vein Compression Syndrome Associated with Thrombosis

PURPOSE: We report our early experience, and the feasibility, of an endovascular technique for treating iliac vein compression syndrome, which is known to be caused by a chronic pulsating irritation of the iliac artery. METHODS: Five patients presented with acute deep vein thromboses in their left legs, diagnosed by computed tomography (CT), and treated with a catheter-directed thrombolysis. The residual stenosis was treated by angioplasty, followed by stent placement. The results were evaluated, followed with duplex ultrasound. RESULTS: The CT scan of the left iliac vein was compressed by the right iliac artery, with the thrombosis shown distal of the venous segment of the crossover point in all five cases. Success with the endovascular technique was achieved in all 5 patients. In the follow up, the duplex scan stent site and patency were examined. During the follow up period all the stents were patent, and no thrombosis recurred. CONCLUSION: A CT scan is helpful in diagnosing iliac vein compression syndrome, with a thrombosis. The endovascular approach for its treatment should be considered affirmative due to its safety and simplicity.

Clinical Significance of Detection of Carcinoembryonic Antigen in Peritoneal Fluid by Reverse Transcription-Polymerase Chain Reaction in Patients with Gastric Cancer

PURPOSE: Free cancer cells in the peritoneal cavity exfoliated from a tumor are considered to be responsible for peritoneal dissemination in gastric cancer. To detect free cancer cells, a carcinoembryonic antigen (CEA) was introduced to the marker of gastric cancer. The clinical significance of detecting the carcinoembryonic antigen (CEA) mRNA in the peritoneal fluid was evaluated by RT-PCR in patients with gastric cancer. METHODS: In 50 patients with gastric cancer who received a gastrectomy, the peritoneal washing fluids were obtained and the CEA mRNA was detected by RT-PCR and a cytological examination was taken, simultaneously. The results were correlated with the stage and the recurrence of peritoneal seeding. RESULTS: Positive values of CEA mRNA from the peritoneal washing fluids were observed in 24% (12/50) of patients with gastric cancer but of 4% (2/50) showed peritoneal cytology. There were 8 cases of peritoneal seeding in the follow-up and 6 cases of them presented positive CEA mRNA values (50%, 6/12). According to the stage, positive CEA mRNA values from the peritoneal washing fluids were found in 9% (2/21) in stage I, 20% (2/10) in stage II, 33% (5/15) in stage III and 75% (3/4) in stage IV (P=0.030). In the T classification, positive CEA mRNA values were found in 13% (2/15) in T1, 10% (1/10) in T2, 30% (7/23) in T3 and 100% (2/2) in T4 (P=0.031). In the N classification, positive CEA mRNA values were found in 15% (4/26) in N0, 20% (3/15) in N1, 40% (2/5) in N2 and 75% (3/4) in N3 (P=0.055). CONCLUSION: These results suggest that the detection of CEA mRNA by RT-PCR in peritoneal fluid of gastric cancer patients was more sensitive than the peritoneal cytology, and may have a role in selecting patients with a poor prognosis who may benefit from adjuvant therapy.

Endoscopic Harvest of Greater Saphenous Vein for Leg Artery Bypass

PURPOSE: The autologous greater saphenous vein (GSV) is the most frequently used graft for leg artery bypass. But vein harvesting with long open incision as traditional method can be complicated by wound problem. Since we experienced endoscopic vein harvesting in leg artery bypass, we reviewed its advantage and indication. METHOD: Six patients received the endoscopic saphenous vein harvesting procedure for their leg artery bypass surgery. The endoscopic procedure was limited above knee avoiding of the injury to saphenous vein because it has more branching at below knee. We studied endoscopic using time, number of branch ligated, wound closure time, wound complication, postoperative pain and admission duration. RESULT: In one patient the procedure was failed because many branch and small GSV. In five patients mean endoscopic using time was twenty two minutes and 2.2 branch was ligated. There was no wound complication. Wound closure time and operation time was decreased but the statistical variables difficult to decide. In one patient for redo operation, contralateral GSV was harvested. CONCLUSION: Endoscopic GSV harvesting is technically simple procedure, which can reduce wound size in using reversed way of GSV in leg artery bypass. We also believe it reduce operation time, wound pain, hospital stay. But it needs further study and skill in our study.

Characteristics of Incompetent Perforating Vein in Medial Calf according to CEAP Classification

PURPOSE: The contribution of perforating vein incompetence to the hemodynamic derangement in the chronic venous disease (CVD) remains a topic of debate. This study was designed to define the characteristics of IPV according to CEAP classification with development of CVD. METHOD: From March 1999, to August 2001, 145 patients were treated for CVD in our hospital. Of these, 15 patients with CEAP class 4, 5, 6 (Group I) and 130 patients with class 2 (Group II). Medial side of calf was assessed in the sitting position for looking IPVs by duplex scan. The number, location, and diameter at the fascia level of IPVs were determined. The characteristics of IPVs between two group were compared. Airplethysmogram (APG) was checked pre and postoperatively in 18 patients with class 2 without any procedure to IPVs. RESULT: 17 IPVs were found in 11/15 (73%) patients in group I, and 36 IPVs were found in 29/145 (20%) in group II. The mean number of IPVs in each limb of group I and II was 1.54, 1.09 (P>0.05) and the mean diameter was 0.52 cm, 0.38 cm (P=0.001). The 96% (51/56) of IPVs were found in lower half of the calf. All hemodynamic parameter of APG was improved statistically significantly after operation without ligation of IPVs in class 2 patients. CONCLUSION: With advancing of CVD (class 4, 5, 6), IPVs was found more and larger. This suggest significant hemodynamic role of IPVs in progression of CVD. So careful attention should be payed to IPVs in treatment of CVD. But it was doubted benefit of direct treatment of IPVs in class 2.

Validation of Duplex Scan in Detecting Distribution of Reflux in Patients with Advanced Chronic Venous Insuficiency and Early Results

PURPOSE: The advanced stage of chronic venous insufficiency (CVI) 4, 5, 6, which shown lipodermatosclerosis, venous ulcer might cause frustrating symptom compared with simple varicose vein. For successful treatment, precise anatomic, hemodynamic information of venous system is recommended. Although there is still controversy, duplex scan is the best way in evaluation of hemodynamic pathology. We studied key role of duplex scan in treatment of advanced CVI. METHOD: From November 1998, to February 2000, 125 patients were treated for CVI in our hospital. Of these 11 patients with class 4, 5, 6 were assessed by duplex scan, ascending venogram, hemodynamic functional studies. All venous segments were eagerly assessed for looking reflux. Except one patient who refuse surgery 10 patients received conventional surgical treatment and endoscopic perforator ligation. The one year follow up results were assessed. RESULT: 9 patients showed superficial venous reflux, 3 patients had deep venous reflux. In all 6 patients who had ulcer, incompetent perforator vein was identified. In 9 patients, stripping 8, high ligation 1, endoscopic perforator vein ligation 3 were done. During 1 year follow up clinical improvement was singificant in these 11 patients assessed with symptom scores. All ulcer were healed with average 25.3 days, and no recurrence. CONCLUSION: Although no single test was enough for perfect assessing CVI, scrupulous examination with duplex scan is best way for accomplishing successful outcome at presents.

Gallbladder Dysmotility and Gallstone Development after Gastrectomy in Gastric Cancer Patients

PURPOSE: Gallstone disease has been presumed to be a sequellae of gastrectomy. To know correlation between gallbladder disease and gastrectomy, we check anatomical and functional status of gallbladder with ultrasonogram in our study. METHODS: Gallbladder motility after gastrectomy was studied by means of measuring fasting and postprandial gallbladder volume using real time ultrasonography in 50 gastrectomized patients and in 28 controls (healthy but not operated gastric cancer patients) were selected as study subjects. RESULTS: Mean fasting and postprandial gallbladder volume was significantly increased in gastrectomized patient group (FV: 37.63+/-20.70 ml, PV: 11.50+/-10.26 ml) than control group (FV: 22.17+/-10.35 ml, PV: 5.44+/-3.67 ml, p<0.01). The ejection fraction of gallbladder in gastrectomized patient group (69.05+/-14.57%)was significantly smaller than control group (75.57+/-10.26%, p<0.05). CONCLUSION: The risk of gallbladder disease was independent of age, sex, and post-operative duration in our study. Gastrectomy may have the possibility of increasing the risk of gallbladder disease by causing gallbladder dysmotility and bile stasis. So, gallbladder motility evaluation would be helpful for prevention and understanding gallstone formation. Further study will be needed about the clinical benefits of prophylactic cholecystectomy during gastrectomy.

Lymphatic, Vessel, and Neural Invasions in Gastric Cancer and Its Significance in Prognosis

PURPOSE: This study was undertaken to investigate the prognostic significance of lymphatic invasion (LI), vessel invasion (VI), and neural invasion (NI) in gastric cancer and their correlations with other standard prognostic variables, such as the TNM stage. METHODS: The case histories of 100 gastric adenocarcinoma patients who had undergone a curative resection from 1992 to 1996 at Taegu Hyosung- Catholic University Hospital, Taegu, Korea were analyzed retrospectively. The Chi-Square test was used to determine the statistical significance of differences, and the Kaplan-Meier method was used to calculate survival rates. Significant differences in the survival rate were assessed using the log-rank test. The cox regression method was used for evaluation of independent prognostic significance. RESULTS: The 2-year survival rate was significantly lower (p<0.05) in LI (+) and NI (+) cases. The correlation between the T stage and LI, VI, and NI was statistically significant. Also, the correlation between the N stage and LI, VI, and NI was statistically significant. In the lymph node (+) group (n=43), the 2-year cumulative survival rate was higher in LI (-), VI (-), and NI (-) cases, but this result was not statistically significant. In the lymph node (-) group (n=57), the 2-year cumulative survival rate was higher in LI (-), VI (-), and NI (-) cases, but only the result for the NI (-) group was significant. Multivariate analysis demonstrated that LI, VI, and NI were not significant factors influencing the prognosis, although they were significant in the univariate analysis. CONCLUSION: This study identifies LI, VI, and NI as possible prognostic factor in gastric adenocarcinoma cases, but more careful research is needed.

Surgical Treatment of Primary Aortoduodenal Fistula: A case report

We experienced a case of a primary aortoduodenal fistula, which was successfully diagnosed and repaired. This diagnosis must be considered in cases of gastrointestinal bleeding with an abdominal aortic aneurysm. If the correct diagnosis can be made promptly, surgical repair of the fistula is possible.

Carotid Artery Resection and Bypass for Malignant Fibrous Histiocytoma of the Head and Neck

Malignant fibrous histiocytoma (MFH) is recognized as the most common soft tissue sarcoma in adult. But it is very rare in head and neck region with less than 100 cases reported in literature. Treatment of choice for MFH is surgery. For wide surgical excision, usually carotid artery resection is unavoidable. For preventing neurologic sequelae we did preoperative carotid artery balloon occlusion test with EEG monitoring. Greater saphenous vein was used for interposition graft.

The Role of Duplex Scan to Surgeon in Treatment of Primary Varicose Vein

PURPOSE: Anatomy and morphology of superficial veins vary from patient to patient. Thorough assessment of variations is mandatory for successful treatment of primary varicose vein. Alos in complex case clinical examination alone is unable to achieve diagnostic goals. Duplex scan is a highly accurate, noninvasive technique that can provide both anatomic and physiologic information. METHODS: Thirty-eight legs in 30 patients with primary varicose veins were examined clinically first then with portable doppler. Patients then underwent duplex scanning by surgical team and results of tests were compared with other clinical examinations. RESULTS: On duplex scanning, 25 legs (66%) had saphenofemoral junction (SFJ) incompetence, 9 legs (24%) had saphenopopliteal junction (SPJ) incompetence and 4 legs (10%) had perforator incompetence. The respective sensitivity of clinical examination with portable doppler in SFJ, SPJ was 91.6%, 81.8%. CONCLUSION: Clinical and doppler assessment was unreliable. Routine preoperative duplex scanning is likely to reduce recurrence by identifying sites of reflux with greater accuracy.

Experience of Balloon Matas Test (BMT) in Carotid Artery Surgery

A temporary balloon occlusion of internal carotid artery (ICA) was performed in 3 patients for carotid artery endarterectomy and 1 patient require sacrifice ICA with neck malignancy. EEG monitoring and neurologic evaluation was done during the test. In one patient who has bilateral ICA stenosis more than 95% shows slurred speech and aphasia during test. Another 3 patients shows no clinical change during test, and operation was done without shunt. There were no postoperative neurologic complication. We believe that preoperative balloon occlusion of ICA provide another helpful criteria to decide using shunt. But it needs another hemodynamic analysis tool according to other's report.