Considerations in the management of aneurysms of the superior mesenteric artery.

Aneurysms of the superior mesenteric artery (SMA) are rare, accounting for 5.5% of all splanchnic aneurysms and <0.5% of all intraabdominal aneurysms. Previous reports have characterized these aneurysms among splanchnic artery aneurysms. However, these aneurysms are quite different in terms of etiology, presentation, and treatment, and their independent consideration is warranted. We report a patient with a traumatic SMA aneurysms who was successfully treated with surgical resection and distal revascularization. We also present an alternative technique of retrograde aorto-SMA bypass using autologous vein that prevents kinking. Also included is a review of the recent literature as it pertains specifically to SMA aneurysms.

Telemedicine and endovascular aortic grafting.

Endovascular aortic grafting represents a minimally invasive approach to aortic aneurysm repair. The technique requires a variety of new skills and extensive training. Telemedicine enhances mentoring and technical support for surgeons performing the technique.

Bifurcated endovascular grafting for abdominal aortic aneurysm.

Endovascular grafting represents a minimally invasive approach to prosthetic aortic grafting for abdominal aortic aneurysms (AAA). We reviewed our initial experience with a bifurcated endovascular graft that shares with conventional grafts the characteristics of discrete transaortic fixation and unitary unsupported woven polyester construction. Twenty-eight patients (26 male, 2 female; age: 58-93) with infrarenal aortic aneurysms between 41 and 82 mm in greatest diameter (x = 55.4 mm) underwent bifurcated endovascular grafting (Guidant/EVT, Menlo Park, CA) over an 18-month period. We concluded that bifurcated endovascular grafting with the EVT(R) device provides reliable and reproducible aneurysm exclusion with short hospital recovery and low morbidity.

Autologous superficial femoral vein for aortic reconstruction in infected fields.

Autogenous reconstruction is one option available for patients with aortic graft infection or mycotic aneurysms. We reviewed our recent institutional experience with all patients undergoing aortic reconstruction using autologous superficial femoral vein (SFV). Between February 1995 and November 1997, eight patients (five with prosthetic aortic graft infection and three with mycotic aneurysms, including one ruptured mycotic aneurysm) underwent single-stage aortic reconstruction using autologous SFV. Therapy for graft infection included graft excision and replacement with aortobifemoral or aortofemoral (with subsequent cross femoral) grafts fashioned from the SFV. The two patients undergoing elective repair of mycotic aneurysms were treated with extensive SFV patches, and the patient with a ruptured mycotic aneurysm underwent SFV tube grafting. Autogenous reconstruction of the aorta using the SFV in infected fields shows promise for salvage of life and limb during early experiences and short-term follow-up. Morbidity and mortality rates compare favorably with those from existing series, reconstruction is anatomic, and reinfection potential is low. Long-term follow-up and more extensive experience with this technique are needed to establish its role relative to other conventional methods.

Postlaminectomy arteriovenous fistula masked by stenosis of the inferior vena cava.

Discovery of a postlumbosacral discectomy fistula between the right iliac artery and vein was obscured by an associated severe stricture of the infrarenal inferior vena cava in a 49-year-old man. During venous stenting for treatment of peripheral edema, the fistula was suspected because of faint pulsatile right iliac vein flow and increased O2 saturation of the venous blood. The suspicion was confirmed on subsequent iliac arteriography. Surgical closure of the fistula with arterial interposition grafting was then performed. The patient improved substantially.

Percutaneous transluminal angioplasty for subclavian artery stenosis.

Treatment of brachiocephalic arterial lesions by percutaneous transluminal angioplasty (PTA) has only recently been performed with sufficient frequency to allow full assessment of its value. In this series, we report our results with PTA of 36 symptomatic subclavian stenoses in 33 patients seen from February 1981 through February 1992. Initial success rate was 94 per cent. There were no deaths and no CNS complications. Five minor complications occurred. Review of published surgical series suggests a similar early success rate but a significantly higher morbidity. These excellent early results of PTA and long-term results from other studies confirm that PTA of subclavian artery stenoses is a safe, highly effective procedure and should be considered the treatment of choice for symptomatic subclavian artery stenoses.

Heparin-induced thrombocytopenia.

Heparin-induced thrombocytopenia (HIT) is a rare complication of heparin with significant morbidity and mortality. In this study, a retrospective review of all patients referred to the platelet study lab at East Carolina University who tested positive for heparin-induced platelet aggregation was performed. From May 1988 through March 1991, 40 patients with clinically suspected HIT were referred for platelet aggregation studies. Ten patients tested positive for in-vitro platelet aggregation in the presence of heparin. The clinical characteristics of these patients are reviewed. Results show a preponderance of surgical patients with 8/10 patients having undergone a primary major surgical procedure. Six of the eight surgical patients underwent a major vascular or cardiac procedure. The mortality rate for patients with heparin-induced in-vitro platelet aggregation was 30 per cent. Major thromboembolic morbidity was substantial (80%) with 5/10 patients requiring an extremity amputation. The estimated incidence of HIT in surgical patients in this series was 0.3 per cent. HIT is an unusual complication of heparin therapy with devastating morbidity and mortality. Patients undergoing a major vascular or cardiac procedure appear to be at increased risk. Increased awareness of the syndrome and careful monitoring of platelet counts in patients at high risk may reduce the morbidity and mortality.

Aortoesophageal fistula: report of a successfully managed case and review of the literature.

Aortoesophageal fistula is a rare, frequently fatal cause of upper gastrointestinal bleeding. Although several causes have been described, it appears that the most common cause is rupture of a thoracic aortic aneurysm into the esophagus, occurring in approximately 12% of thoracic aneurysm ruptures. Although the entity was originally described in 1818, the diagnosis has rarely been made before death, and until 1983 no one survived surgery for aneurysm-associated aortoesophageal fistulas. Since that report of two cases, only two other survivors, including this patient, have been reported. Included herein is the report of a successfully managed case, along with a discussion of the causes, clinical features, and diagnostic approach to the disease, as well as the management of both the aortic and esophageal components of the fistula.

Diagnosis of pancreatic allograft rejection by measurement of urinary radioimmunoreactive insulin.

The accurate, early, and sensitive diagnosis of pancreatic allograft rejection is one of the major problems in clinical pancreas transplantation today. Pancreaticocystotomy is a popular technique for pancreas transplantation that permits simple and frequent urinary chemistry examinations. In this experiment, 20 mongrel dogs with a bladder-drained pancreatic transplant had serial monitoring of urinary amylase (UA) and urinary insulin (UI). The mean UI in the nonrejection state was 9.6 +/- 12 mIU/L. In eight dogs varying degrees of rejection were documented by histopathology. All three animals having severe acute rejection had high levels of IU (all greater than 300-800 mIU/L). Of the five animals with mild-to-moderate rejection, all had significant UI elevations to greater than 100 mIU/L but none had elevations above 200 mIU/L (P less than 0.05 for all groups). Ten animals were treated with prednisone, Imuran, and cyclosporine (CsA), and five of these dogs had good graft function for greater than 14 days, during which the mean UI was extremely low (11 +/- 6.4 mIU/L, P less than 0.05). These values were not significantly different from the 0-14-day values for three pancreas autotransplants with bladder drainage (8.9 +/- 7.2 mIU/L, P less than 0.05). All rejections were preceded by significant rises of UI occurring two to five days prior to rejection. In seven animals, early graft dysfunction (1-4 days) developed, with total graft necrosis by five days. This graft injury was presumably caused by preservation damage or early vascular thrombosis and was associated with early (1-4 days) marked elevations of the UI (greater than 300 mIU/L). None of the animals with grafts surviving to rejection at seven days or more had these early severe elevations, and thus these early UI rises are pathognomonic of graft damage. In contrast, UA and lipase showed inconsistent association with rejection or early damage, although falls in UA generally occurred at or following the time of rejection. Marked daily variations in UA measurements were the most difficult aspect of UA monitoring. Serial electromagnetic flow probe studies of blood flow to the pancreas graft showed a good correlation between loss of blood flow and rises in UI associated with early graft injury. These results suggested that the UI assay gives a sensitive, early, accurate, and specific differential prediction of pancreas graft dysfunction. Specifically, the UI assay appears to be of value not only in the early differential diagnosis of graft injury and graft rejection, but also in the assessment of the severity of rejection.(ABSTRACT TRUNCATED AT 400 WORDS)