Pulmonary sporotrichosis with massive hemoptysis.

Pulmonary sporotrichosis is an uncommon condition that may mimic tuberculosis. We present a patient who, years after antifungal therapy, presented with massive pulmonary hemorrhage. Although such life-threatening hemoptysis caused by sporotrichosis is rare, the possibility of this complication of progressive disease should influence decisions regarding medical and surgical treatment of patients with extensive cavitary involvement.

Intracranial hemorrhage after carotid endarterectomy.

Among 1500 carotid endarterectomies performed between 1975 and 1984, 11 ipsilateral intracranial hemorrhages (IH) occurred between the first and tenth postoperative days for an incidence of 0.7%. The mortality rate among these patients was 36%. The only recognizable predisposing factor was relief of high-grade carotid stenosis (greater than 90%) whereas other factors such as age (58 to 81 years), preoperative hypertension (systolic blood pressure 120 to 160 mm Hg), preoperative head CT scans showing recent infarction (only one in five positive), and preoperative cerebral infarction (only 1 of 11 patients) did not play a role. All patients had normal coagulation studies. No patient required a shunt because all tolerated cross-clamping of the carotid artery. Postoperative systolic blood pressures were 200 to 240 mm Hg in 6 of 11 patients. The time of occurrence of IH extended from the immediate postoperative period to the tenth postoperative day (mean interval 3.3 days). Treatment consisted of craniotomy in five patients; four survived and one recovered completely. Of the six patients treated nonoperatively, three survived and two completely recovered. IH shares equal incidence with recurrent thrombosis, cross-clamping ischemia, and embolization as a cause of perioperative stroke. Although all except IH can be prevented by current practice, the means of preventing IH are not apparent; however, careful monitoring of blood pressure to prevent uncontrolled hypertension deserves consideration.

Ruptured abdominal aortic aneurysm presenting as symptomatic inguinal mass: report of six cases.

Six elderly male patients (mean age, 73 years; range, 66 to 78 years) were admitted with groin masses caused by ruptured abdominal aortic aneurysms. A palpable abdominal mass was present in 33%. All patients eventually underwent abdominal aortic aneurysmectomy with a resultant mortality rate of 50%. Delayed diagnosis, preoperative hypotension, advanced age, poor nutritional status, and excessive intraoperative blood loss were factors contributing to this high mortality rate. In this unusual clinical presentation of ruptured abdominal aortic aneurysm, a high index of suspicion by the emergency room staff and prompt surgical intervention are mandatory to improve mortality rates. The anatomy of the retroperitoneal space and the phylogenetic development of a channel between the scrotum and the kidney are important factors in the development of this symptom complex.

Linton patch angioplasty. An adjunct to distal bypass with polytetrafluoroethylene grafts.

Expanded polytetrafluoroethylene (PTFE) grafts have shown promise in bypasses to the popliteal and tibial arteries, but a significant incidence of immediate and late graft failure has limited general acceptance. Compliance differences between the PTFE graft and artery may present technical difficulties in small vessel anastomosis, as well as being implicated in late development of intimal hyperplasia. A retrospective study of 68 patients who had bypass to the distal popliteal and tibial arteries using PTFE grafts with adjunctive distal patch angioplasty was undertaken. Operation was done for limb salvage in 85%. Runoff was marginal in 69%. A venous patch was sutured to the distal artery and the PTFE graft was then sutured into an opening in the proximal portion of the patch. There was one early graft occlusion. Cumulative patency was 97% at 1 month, 92% at 3 months, 87% at 6 months, 74% at 12 months, and 65% at 24, 36, and 48 months. A distal autogenous vein patch permits precise suturing of the distal anastomosis and minimizes technical difficulties leading to early graft failure. Improvement of the compliance mismatch of the PTFE graft and artery may impede the unwelcome development of intimal hyperplasia at the distal anastomotic site. The adjunctive use of a distal patch has resulted in excellent immediate graft patency, despite a high incidence of poor run-off and limb salvage situations.

The use of Mersilene mesh in repair of abdominal wall hernias: a clinical and experimental study.

Use of synthetic materials in herniplasty has been a controversial issue. In order to determine the influence of Mersilene mesh on the strength of healing abdominal wounds and its effectiveness in repair of hernia, experimental and clinical studies were undertaken. Experimental study included 175 male rats divided into three groups subjected to either: 1) an incision made only through the skin and closed with 3-0 silk sutures; 2) a 2.5 cm midline incision through the musculature and peritoneum closed with 2-0 Mersilene suture; or 3) the same procedure as group 2 with the addition of a Mersilene mesh onlay graft. Bursting strength of abdominal wounds as determined in all groups at intervals. Wounds of the group treated with the mesh exhibited significantly greater (P less than 0.01) bursting strength. Clinical trial consisted of 100 consecutive adult patients in which an onlay graft of Mersilene mesh was used in the hernioplasty. Mesh was used as an adjunct in patients with: 1) large ventral hernias; 2) direct hernias resulting from severely attenuated transversialis fascia; 3) indirect hernias associated with a large internal ring and a weak posterior inguinal wall; or 4) combined direct and indirect hernias. All were followed for a minimum of one year to determine the incidence of complication and rate of recurrence. This study suggests that: 1) Mersilene mesh increases the strength of healing abdominal wounds in rats; and 2) repair of large hernias with Mersilene mesh results in an acceptable morbidity and a lowered rate of recurrence.