Value of ultrasound guidance in placement of hemodialysis access catheters in patients with end-stage renal disease.

The increasingly frequent use of ultrasound for the placement of central venous catheters has shown improved results. This study examined the role of ultrasound in the placement of hemodialysis access catheters in patients with end-stage renal disease. The subjects were all end-stage renal disease patients admitted to our hospital between January 2004 and April 2005 and who underwent ultrasound-guided placement of a hemodialysis catheter in a central vein. All patients underwent perioperative ultrasound assessment of the venous access site, followed by fluoroscopic confirmation of the catheter placement. Data from medical charts and the hospital computer system were subjected to statistical analysis. A total of 126 patients underwent ultrasound-guided placement of a hemodialysis catheter in a central vein; 58 had undergone prior placement of a central vein catheter, but 69 had not. Patients in the later group had a 100 per cent success rate in catheter placement after ultrasound assessment of one central vein. Among patients who had previously undergone central vein catheterization, 29 had jugular venous occlusion, 12 had bilateral jugular venous occlusion and thus required placement of femoral venous catheters and, 15 patients had jugular vein stenosis and 2 patients had the jugular vein thrombosed. The use of ultrasound to assess the central veins facilitated the identification of vein suitable for catheterization and the avoidance of occluded centralveins. This protocol is effective and improves patient safety.

Endovenous laser ablation of saphenous vein is an effective treatment modality for lower extremity varicose veins.

We present our first experiences with the use of a new minimally invasive treatment of lower extremity varicose veins. We studied the occlusion rates of the great saphenous vein (GSV) with laser ablation, its failure rates, and its complications. Sixty-six limbs in 62 consecutive patients were treated and followed-up for 1 year. All of the patients had incompetent GSV proven by means of duplex scanning. The GSV segment from 2 cm distal to the sapheno-femoral junction to just above the knee was ablated by using laser energy. In addition, all patients had stab avulsions of the varicose veins of the leg with Crochet hooks. All patients were followed postoperatively on the 3rd day, 1 month, 3 months, and 1 year after surgery. All patients were treated as day-case surgeries. Among 62 patients studied, 46 patients were women (74%) and 16 were men (26%). The median age of the patients was 53 years (range 28-69 years). Median operation time was 65 min (range 40-140 min). Successful treatment (total obliteration of the GSV on duplex) was accomplished in 64 of 66 limbs (97%). In two cases, recanalization of the lower one-third of the treated segment of the GSV was noted after 3 months. There were no instances of neuropathy or skin burn. Endovenous laser ablation of varicose veins is effective in inducing thrombotic vessel occlusion and is associated with only minor adverse effects. The procedure seems to be a promising alternative for surgical stripping of the GSV.

A decade of experience with abdominal aortic aneurysm repair in octogenarians.

BACKGROUND: Should abdominal aortic aneurysms (AAA) be electively repaired in octogenarians? METHODS: This was a retrospective review of patients' charts over a ten-year period starting in January 1995. This study was conducted at St. Francis Hospital, Roslyn, New York, which is a tertiary referral center. All octogenarians who underwent AAA repair (elective and emergent) were included in this study (mean age 82.9 years). A total of 71 such patients were identified. Sixty-two patients had elective surgery and nine patients had emergent repair of the ruptured AAA. It was hypothesized before the study was conducted that AAA could be repaired in octogenarians with acceptable morbidity and mortality in an institution with vast experience in dealing with this disease. RESULTS: The mean aneurysm diameter was 6.73 cm. Twenty patients (28%) received bifurcated grafts, while 51 patients (72%) received tubular grafts. Four patients had coronary artery bypass graft before aneurysm surgery. Forty-four patients (62%) were male and 27 (38%) were female. The thirty day mortality rate after elective AAA repair was 1.4%, whereas after the repair of ruptured aneurysms was 44.4%. CONCLUSIONS: We concluded that the elective repair of abdominal aneurysms in most octogenarians is a safe and life-prolonging procedure if performed in an experienced tertiary center.

Histoplasmosis of the small bowel in patients with AIDS.

Two cases of jejunal strictures caused by Histoplasma capsulatum in AIDS patients are presented. Both patients were intravenous drug abusers. One patient, who was being treated for Pneumocystis carnii pneumonia, presented with jejunal perforation and the other presented with lower gastrointestinal bleeding and intestinal obstruction. On exploration, both patients were found to have jejunal strictures; one had intestinal perforation, and the other had intestinal obstruction with ulcers and strictures resulting in gastrointestinal bleeding. In areas where it is endemic, histoplasmosis is rarely disseminated. Dissemination is most commonly seen in immunosuppressed patients. Dissemination and extrapulmonary histoplasmosis is now included in the case definition of AIDS.

Lobular carcinoma-in-situ within a fibroadenoma of the breast.

We present a case of an in-situ lobular carcinoma within an otherwise benign fibroadenoma in a 45-year-old woman.

Experience with invasive Candida infections.

Between January and July 1995, 227 patients at the Bronx-Lebanon Hospital Center had positive fungal cultures. Candida spp were the most common fungi isolated. Forty-three patients with invasive disease, as indicated by fungus-positive blood cultures, became the focus of our study. C albicans caused fungaemia in 21 patients (49%). Twenty-eight patients (65%) were less than 50 years of age; three were neonates. The most common presenting symptoms were fever, chills, and weakness (20 patients, 47%). Thirty patients died, giving a mortality rate of 70%. The patients who died stayed in the hospital an average of 49 days. The highest mortality occurred among patients who became bacteraemic before or at the same time they became candidaemic (24 of 26 patients) or who were receiving broad-spectrum antibiotics (20 of 26 patients). We also found high mortality rates from invasive fungal infection among patients with HIV infection, a central venous catheter, and liver, renal, or respiratory failure. We did not find any increase in the incidence of invasive fungal infection or mortality among leukopenic or diabetic patients.

Syncytial variant of nodular sclerosing Hodgkin lymphoma.

We report the case history of a 31-year old woman with a rare morphologic form of nodular sclerosing Hodgkin disease (NSHD) termed "syncytial variant." Its histologic features mimic metastatic carcinoma, thymoma, melanoma, non-Hodgkin lymphoma and germ-cell tumor. Antigens expressed on Reed-Sternberg cells, the hallmark of Hodgkin disease, and other neoplastic cells were screened to determine the correct diagnosis. This patient demonstrates the importance of using specific immunohistochemical techniques to clarify the diagnosis of NSHD of the "syncytial variant" subtype.

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.

Modern management of postoperative pain.

In the last 10 years there has been an increased awareness of the need for improved pain management, especially in the postoperative period, to a large extent stimulated by the US Agency for Health Care Policy and Research (AHCPR), which published its clinical practice guidelineS for pain management in 1992. Teams of surgeons, nurses and anesthesiologists now are combining modalities for managing pain so as to provide the most comfortable postoperative course possible for their patients.

Eccrine porocarcinoma.

Eccrine porocarcinoma is a malignant tumor of eccrine sweat glands. It is a very rare, slow growing tumor and clinically resembles other skin cancers. We report a case and review its clinical and pathological features. These tumors have a propensity for local recurrence, and wide excision with negative margins is recommended.

Aneurysm of the right colic artery.

Aneurysms of the superior mesenteric artery branches are rare. Spontaneous intra-abdominal hemorrhage resulting from rupture of a visceral artery aneurysm is difficult to diagnose and carries high mortality. We present a case in which a rupture of the right colic artery aneurysm presented as an acute abdomen. Diagnosis was established intraoperatively. Angiography and a high degree of suspicion are valuable diagnostic tools. Exact etiology was not determined in our case. Because of high risk of rupture, aneurysms of the superior mesenteric artery branches should be resected.

Lower extremity revascularization.

Atherosclerotic occlusive disease of the lower extremity in patients exhibiting severe rest pain, ulceration, or tissue necrosis represents a serious threat to extremities. In the past two decades the surgical approach in the treatment of lower extremity ischemia has changed significantly due to better understanding of segmental disease and infrapopliteal disease. Also, better visualization of leg and foot arteries due to improved angiographic and surgical techniques aided by magnification have all significantly contributed to increased limb salvage. Vein, when available, is the ideal graft material both for supra and infrapopliteal reconstruction. Availability of vein as a conduit can be increased when ectopic veins such as cephalic etc., are used and also when short segments of veins are used with unconventional distal inflow sites such as SFA, distal deep femoral artery, and popliteal artery. However, when vein is unavailable, PTFE graft is a good option particularly in patients with life expectancy of less than three years. Better understanding of graft failure has lead to better graft surveillance with PVR, ABI and Duplex scanning. Timely intervention with either PTA or surgery has lead to better secondary patency of grafts. Veith et al. looked at amputation rates during the period of changing therapeutic approach and found both a decrease in primary and secondary amputation rate implying the effectiveness of an aggressive therapeutic approach. Not all aspects of lower extremity disease are understood. However, infrapopliteal disease has now been addressed and new, innovative therapeutic approaches have made significant advances in limb salvage.

Venous patch grafts and carotid endarterectomy. A critical appraisal.

Seventy-eight patients underwent 83 carotid endarterectomies (CEAs) with vein patch grafts from 1980 to 1985. A technically satisfactory endarterectomy was confirmed by completion arteriogram in all instances. Indications for venous patch graft included a diameter of the internal carotid artery of less than 3.0 mm (49 patients); an internal carotid artery diameter of less than 3.5 mm, with contralateral internal carotid artery occlusion (nine patients); unexpected stenosis detected by completion arteriogram (six patients); a reexploration for neurologic deficit following conventional CEA (three patients); and irregular surface or edges of the endarterectomy site or high extension of a plaque (16 patients). Late follow-up arteriograms (66 studies) after a mean two-year interval revealed three instances (4.5%) of recurrent asymptomatic stenosis. Four patients (6%) developed late occlusions; three were asymptomatic and one was associated with major stroke 2 1/2 years later. One patient (1.5%) developed a false aneurysm. One patient experienced a postoperative transient ischemic attack. There was no operative mortality. Six patients died in the late follow-up period. The venous patch graft ensured immediate patency of the internal carotid artery but failed to prevent recurrent stenosis or occlusion in internal carotid arteries less than 3.0 mm in diameter.