Pseudo-aneurysm of the carotid bifurcation secondary to radiation.

Pseudoaneurysms of the extracranial carotid vessels have a varied etiopathogenesis. Cases have been attributed to spontaneous rupture, following tonsillectomy or peritonsillar abscesses, trauma, postanastamotic and, rarely, postirradiation, and ECMO. The authors present a case of a pseudoaneurysm involving the carotid artery bifurcation following radiation therapy. A saphenous vein graft was used to establish continuity between the common and the internal carotid arteries. A vascular shunt was used to maintain cerebral perfusion during surgery. This case highlights the technical difficulties encountered in correcting this condition. This case exemplifies the technical difficulties that are encountered in a complicated case such as this. Numerous previous operations and radiotherapy compounded the hazards of the surgical procedure. Although technically challenging, every attempt must be made to resect pseudoaneurysms caused by radiation induced vascular damage.

Plasma elastase in venous disease.

The plasma elastase level was measured as a marker of neutrophil degranulation in three groups, each of 15 patients, with uncomplicated varicose veins, lipodermatosclerosis (LDS) and venous ulceration. The values obtained were compared with those in age- and sex-matched control subjects. Significantly higher levels of elastase were found in all patient groups compared with controls: median 25.6 ng/ml for patients with uncomplicated varicose veins, 22.1 ng/ml for those with LDS, 26.0 ng/ml for those with venous ulceration. There was no difference in neutrophil count between the patient and control groups. These results provide evidence of increased neutrophil degranulation in patients with venous disease. The finding of raised elastase levels in all three patient groups shows that this was not due solely to the inflammatory process characterizing LDS and venous ulceration.

Peripheral thrombolysis with tissue plasminogen activator. Results of two treatment regimens.

OBJECTIVE: The purpose of this study was to document the response to tissue plasminogen activator given as either a low-dose intra-arterial infusion or a bolus infusion in patients with peripheral arterial or bypass graft occlusion. DESIGN: Fifty thrombolytic procedures were carried out in 45 patients with a recent occlusion of a peripheral artery (41) or bypass graft (nine). A continuous infusion of 1.0 mg/h of tissue plasminogen activator was used in 27 patients (group A), while 23 patients were given a 20-mg bolus followed by an infusion of 1.0 mg/h (group B). Patients in the two groups were followed up for 12.1 +/- 9.3 months and 11.1 +/- 9.1 months, respectively. RESULTS: In group A, the angiographic lysis rate was 74% and clinical success rate was 67%. In group B, the comparable rates were 70% and 48%. Lysis was quicker when a bolus infusion was used, the mean lysis time being 14.4 +/- 7.9 hours compared with 26.7 +/- 9.4 hours following infusion alone (P = .0005). There was one instance of major hemorrhage in group A and eight in group B (P = .0022), including two patients with cerebral hemorrhage, one of whom died. CONCLUSION: Low-dose tissue plasminogen activator infusion is safe and reasonably effective, although a long treatment time is required. A bolus infusion regimen speeds lysis but is attended by a high incidence of serious hemorrhage.

Thrombolysis with tissue-plasminogen activator: results with a high-dose transthrombus technique.

PURPOSE: Low-dose intraarterial tissue plasminogen activator (t-PA) is effective in peripheral thrombolysis but treatment time is prolonged. The aim of this study was to determine whether a transthrombus bolus of t-PA before low-dose infusion shortens lysis time. METHODS: Twenty-three patients with peripheral arterial or bypass graft occlusion were treated with an initial bolus of 20 mg t-PA followed by a continuous infusion of 1 mg/hr. RESULTS: Angiographic lysis was achieved in 16 patients (70%) with a mean time to complete lysis of 14.4 +/- 7.9 hours. Two patients had reocclusion on days 1 and 3, respectively. There were three deaths within the first week of treatment, one from cerebral hemorrhage and two from myocardial infarction. A clinically successful outcome was achieved in 11 patients (48%). Those patients with patency at 1 week maintained this response at a mean follow-up of 11.7 +/- 9.1 months. Thrombolysis was unsuccessful in seven instances. In three of these cases the infusion had to be discontinued prematurely because of serious hemorrhage. Of the seven unsuccessful cases, three patients subsequently underwent a femorodistal bypass, two were left with tolerable ischemic symptoms, and two required a major amputation. There were eight major bleeding complications (35%), four at or adjacent to the catheter entry site and four at a distance, including two cases of cerebral hemorrhage, one of which was fatal. CONCLUSIONS: Transthrombus bolus delivery of tissue plasminogen activator followed by a low-dose infusion shortens lysis time, but this technique appears to be associated with an increased risk of serious hemorrhage.

Thrombolysis in acute lower limb ischaemia.

For the past three decades balloon embolectomy has been the treatment of choice for acute lower limb occlusion. However, although usually successful in emboli, results are often disappointing in thrombotic atherosclerotic vessels. Attempted dissolution of the clot is accordingly attractive, and has theoretically been possible since the introduction of streptokinase in 1933. This was initially used intravenously, with variable success rates, although intraarterial administration is currently the method of choice. Later thrombolytic drugs such as tissue plasminogen activator, urokinase and anistreplase have been introduced. Lysis time has also been increased by using pharmaco-mechanical methods of administration such as pulsed spray catheters, which could increase the usefulness of thrombolysis in patients with rapidly progressive neurological signs where currently surgical embolectomy would be advocated. Several newer drugs with theoretical advantages over older drugs such as single-chain urokinase-type plasminogen activator or K1K2PU are currently undergoing trials. The role of thrombolysis as an adjunct to surgical embolectomy is also promising, though again requires further trials. There is still no consensus as to which patients are best suited to thrombolysis, nor an optimum drug or method of administration. However, there seems no doubt that thrombolysis will be increasingly used in the management of peripheral limb ischaemia, though requiring a team approach between surgeons, radiologists and haematologists.

Abdominal wall abscess--an unusual primary presentation of a transverse colonic carcinoma.

Carcinoma of the transverse colon presenting as an abscess of the anterior abdominal wall is a rare occurrence. Such a case is presented, where all investigations failed to show the nature of the lesion. The literature has been reviewed and the pathology that characterizes such lesions, and their management in the light of their favourable prognosis, is discussed. Occult colonic carcinoma should be considered in the differential diagnosis of such abscesses.

Use of Blount's epiphyseal staples to control massive iliac venous haemorrhage.

Significant injuries to major veins are life-threatening events and may lead to patient exsanguination. Treatment usually consists of direct suture repair. A case in which a serious iliac venous haemorrhage was not able to be controlled with the usual surgical procedures is reported. A desperate attempt to achieve haemostasis using orthopaedic staples was successful. The simplicity of this technique makes it a useful addition to the surgeon's armamentarium when dealing with life-threatening venous haemorrhage.