Critical limb ischemia.

Critical limb ischemia refers to the clinical state of advanced arterial occlusive disease, placing an extremity at risk for gangrene and limb loss. Critical limb ischemia has 2 broad clinical subcategories that are vital to differentiate: acute limb ischemia and chronic arterial occlusive disease. This article reviews the etiologies, diagnosis, and treatment of critical limb ischemia.

Spontaneous rupture of a saccular intrahepatic artery aneurysm.

Hepatic artery aneurysms are the second most common visceral aneurysm but are still relatively uncommon. Over the last century, methods for treating these lesions have evolved substantially. The presented case covers the presentation, diagnosis, and treatment of a 65-year-old woman with an aneurysm of the intrahepatic portion of the hepatic artery. This case demonstrates the variety of techniques available for managing these lesions and the importance of both a thorough knowledge of the available treatments and the flexibility to switch among them when necessary.

In situ aortic thrombosis secondary to intra-abdominal abscess.

BACKGROUND: Abdominal aortic mural thrombus is uncommon in the absence of aneurysm or atherosclerosis. CASE REPORT: We report the case of a 46-year-old man who presented to our institution with perforated appendicitis for which he initially declined surgery. Four days after admission he ultimately consented to appendectomy and abdominal washout. Follow-up imaging to evaluate for intra-abdominal abscess revealed mural thrombus of the infra-renal abdominal aorta extending into the left iliac artery. This thrombus was not present on the admission CT scan. The patient had no clinical signs of limb ischemia. Conservative treatment with therapeutic anticoagulation resulted in resolution of the thrombus. CONCLUSIONS: While portal, mesenteric, and major retroperitoneal venous thrombosis are well associated with major intra-abdominal infection and inflammatory bowel disease, aorto-iliac arterial thrombus formation in the absence of associated aneurysm, atherosclerosis or embolic source is exceedingly rare. We are unaware of other reports of in-situ aorto-iliac arterial thrombus formation secondary to perforated appendicitis.

External iliac artery dissection secondary to endofibrosis in a cyclist.

Endofibrosis of the external iliac artery is an uncommon disease affecting primarily young, otherwise healthy, endurance athletes. Thigh pain during maximal exercise with quick resolution postexercise is characteristic of the so-called cyclist's iliac syndrome. We report an unusual case in which the typical endofibrotic plaque was accompanied by dissection of the external iliac artery. The patient was treated surgically with excision of the affected artery segment and placement of an interposition graft. This case highlights an unusual finding in association with external iliac artery endofibrosis and provides an opportunity to briefly review the literature on the subject.

Predictors of electrocardiographic change, cardiac troponin elevation, and survival after major vascular surgery: a community hospital experience.

Cardiovascular disease is the leading cause of perioperative morbidity and mortality after vascular surgery. The purpose of this study was to identify risk factors for myocardial ischemia after vascular surgery and to investigate a potential association of ischemia with mortality in a community hospital setting. A retrospective review was conducted after 190 major vascular procedures. Electrocardiogram (ECG) results and troponin I levels were obtained serially during the first 24 postoperative hours. Outcomes analyzed were ischemic ECG changes, troponin I level more than 2 ng/mL, 6-month mortality, and overall survival. The authors investigated any association of these outcomes with each other and the type of operation, history of coronary artery disease, diabetes, recent coronary intervention, age older than 70 years, or postoperative symptoms. Twenty-seven (14%) patients experienced ischemic ECG changes. Twenty-one (11%) patients experienced troponin I elevation. Univariate analysis revealed a history of coronary artery disease, diabetes, concerning symptoms, and troponin elevation to be predictive of ECG change (P < 0.05). ECG change and symptoms were predictive of troponin elevation (P < 0.01). Cox multivariate analysis revealed only infrainguinal bypass to predict 6-month mortality (odds ratio = 2.92, P = 0.02). Diabetes was the sole predictor of overall mortality (odds ratio = 1.94, P = 0.001). Nonsustained ischemic postoperative ECG changes during the first 24 postoperative hours do not independently influence 6-month or overall mortality after major vascular surgery. Postoperative troponin elevation likely conveys a mortality risk in the subsequent 6 months. In the community hospital setting, midterm survival rates after vascular surgery equivalent to those in higher volume centers can be achieved. Patients undergoing infrainguinal bypass and diabetics continue to be the most moribund vasculopaths.

Aberrant right hepatic artery in laparoscopic cholecystectomy.

INTRODUCTION: Presented herein is a case in which an aberrant right hepatic artery (RHA) passes anterior to the infundibulum and fundus of the gallbladder and courses to an unusually anterior hepatic entry. CASE REPORT: A 54-year-old female with a history of biliary colic was scheduled for laparoscopic cholecystectomy. Laparoscopic dissection revealed an aberrant right hepatic artery (RHA) anterior to the infundibulum and fundus of the gallbladder. Further dissection revealed the cystic artery to branch laterally off this RHA over the gallbladder fundus anteriorly. The cystic artery then wrapped posterolaterally on the gallbladder's surface to its neck. After the gallbladder was removed, the aberrant RHA was readily visible traveling across the gallbladder bed and entering the liver at an unusually anterior location. Intraoperative images are included. The procedure was completed laparoscopically without complication. DISCUSSION: The origins and paths of both the cystic and right hepatic arteries have several documented anomalies. We are unaware of any reports of an RHA that transverses the entire neck and fundus of the gallbladder before such an anterior hepatic entry. CONCLUSION: This case serves as a striking reminder of the variations in extrahepatic biliary and vascular anatomy. Ligation of this uniquely located aberrant RHA could have led to intraoperative hemorrhage or potential hepatic ischemia.

Chronic abdominal pain secondary to a mucous cystadenoma of the appendix in a 10-year-old boy.

Mucocele of the appendix is a thin-walled dilated appendix filled with mucus. It occurs secondary to chronic obstruction of the appendiceal lumen because of a range of pathologies. Cystadenomas in children are exceedingly rare and most frequently of ovarian origin. A mucous cystadenoma of the appendix in a 10-year-old boy with chronic abdominal pain is presented.

Percutaneous biopsy in evaluation of lung nodules.

Management of an indeterminate pulmonary nodule is a diagnostic challenge that commonly confronts primary care physicians and specialists. Patients often present with this radiographic finding in the course of an unrelated medical evaluation. We examined our institution's experience with percutaneous biopsy of lung nodules to determine the impact of this procedure on overall patient care. Although significant complications are uncommon, the expedience of percutaneous lung biopsy often supplants a surgical opinion prior to initiation of therapy without added diagnostic benefit or cost-savings. Hence, we caution practitioners to use this technique as an adjunct to diagnosis and not a substitute for multidisciplinary care.