Inferior mesenteric artery aneurysm. Case report.

This paper reports a large inferior mesenteric artery aneurysm discovered incidentally during the work-up in a male patient with a thoracoabdominal aortic aneurysm. Aortography disclosed an aneurysm in the inferior mesenteric artery with a large marginal artery which filled the branches of the coeliac and superior mesenteric arteries retrogradely. The thoracoabdominal aortic aneurysm was reconstructed by a bifurcated aorto-biiliac Dacron graft while inferior mesenteric artery revascularisation was achieved with a PTFE graft, reconstruction being necessary because of its dominant blood supply to all of the viscera. This case highlights the importance of aneurysmal reconstruction when an anomalous arterial supply to the gastrointestinal tract from a dilated inferior mesenteric artery has been demonstrated on a preoperative angiogram.

The technique of eversion carotid endarterectomy.

Eversion endarterectomy of the Internal Carotid Artery (ICA) has been employed as a good alternative method to classical carotid endarterectomy. The details of this technique are presented. The main operative steps are: complete transection of the ICA from the carotid bifurcation, eversion endarterectomy of the ICA, endarterectomy of the External Carotid Artery, reimplantation of a the ICA to its normal position and reconstruction of a new bifurcation. The major advantages of this attractive technique are optimum correction of an elongated ICA in combination with stenosis, avoidance of patch material for arteriotomy closure and low restenosis rate.

Primary aortocaval fistula in association with ruptured aneurysms.

We report three cases in which ruptured aneurysm and aortocaval fistula went undetected until surgery was performed. Preoperative features suggestive of an arteriovenous fistula were not apparent in any of these patients; they all presented with cardiovascular collapse and all underwent emergency laparotomy after a ruptured abdominal aortic aneurysm was diagnosed. The fistula was discovered unexpectedly only after the aneurysmal sac was opened and the thrombus evacuated. In the first two patients the fistula was successfully sutured from within the aneurysmal sac. The first patient died 1 week postoperatively from rupture of a previously known associated thoracic aortic aneurysm and the second patient died during the operation from excessive blood loss. The third patient had a large fistula requiring an interposition synthetic graft to restore the continuity of the vena cava; the graft has remained patent 15 months postoperatively. Aortocaval fistula is an uncommon complication of aneurysmal aortic disease and may coexist with a rupture of the aneurysm into the retroperitoneum. In emergency cases such as ours it is usually discovered unexpectedly during the operation. The established method of treatment is to oversew the fistula from within the aneurysm; however, when the fistula is large reconstruction of the infrarenal inferior vena cava with an interposition synthetic graft is a good alternative to caval ligation.

Transposed basilic vein-brachial arteriovenous fistula: an alternative vascular access for hemodialysis.

Twenty-five brachial-basilic arteriovenous (AV) fistulas with transposed basilic vein for alternative vascular access were created in 22 chronic hemodialysis patients. This surgical procedure was performed under brachial block or general anesthesia. After a longitudinal skin incision that was made in the inner side of the arm, the basilic vein was exposed, transposed subcutaneously, and anastomosed end-to-side to the brachial artery. The follow-up was between 7 and 24 months. Early complications were hemorrhage, thrombosis, steal syndrome, and swelling of the arm. Among the late complications were failure of the fistula because of thrombosis and multiple stenosis at the site of venipuncture. The accumulated one-year patency rate of fistulas was 81%. The complications of high-output cardiac failure or local infection were not seen in our study. On the basis of our results, the brachial-basilic AV fistula with transposed basilic vein is a useful and safe second- or third-choice vascular procedure for hemodialysis patients, in particular for women without good quality of vessels.