Wound hematomas after carotid endarterectomy.

Wound hematomas, following carotid endarterectomy, are uncommon but potentially lethal complications. The management of 13 patients with this condition is presented. Factors that appeared to predispose to hematoma formation included perioperative use of platelet inhibitory drugs and postoperative hypertension. When the diagnosis of neck wound hematoma is made after carotid endarterectomy, prompt evacuation under local anesthesia is recommended.

Wound hematomas after carotid endarterectomy.

Fifteen of 596 (2.5 percent) carotid endarterectomies performed at Brooke Army Medical Center were complicated by significant wound hematomas requiring reoperation and hematoma evacuation. The wound hematomas resulted from capillary oozing in 80 percent of the cases and arteriotomy bleeders in 20 percent of the cases. Antiplatelet therapy and postoperative hypertension appear to be significant factors predisposing to the development of wound hematomas. In eight cases, local anesthesia was utilized for the hematoma evacuation, and there were no complications. When general anesthesia was utilized for hematoma evacuation, there was considerable difficulty with airway management in six of seven patients. Complications developed in four of these patients. One patient had respiratory insufficiency secondary to laryngeal edema. Two of the patients sustained myocardial infarctions, one of whom died, and a dense neurologic deficit developed in the fourth patient who died as a result of this complication. Meticulous surgical technique in obtaining hemostasis, control of postoperative hypertension, and wound drainage when indicated will help reduce the incidence of postoperative wound hematoma. When a significant postoperative wound hematoma does complicate carotid endarterectomy, the hematoma should be promptly evacuated utilizing local anesthesia.

Anastomotic aneurysms.

Although the incidence of anastomotic false aneurysms decreased precipitously with the cessation of usage of silk sutures for vascular anastomoses, the prevalence of these aneurysms has undoubtedly increased in keeping with an ever-increasing volume of peripheral vascular operations. Most aneurysms occur at femoral anastomoses and are easily diagnosed, since most patients present with a groin mass. Anastomotic aneurysms cannot be considered innocuous. Some may rupture and others have been associated with limb ischemia due to acute thrombosis or embolism. Thus, surgical correction is indicated for most anastomotic aneurysms. Patients at high risk with small aneurysms in accessible locations may, however, be followed if they are asymptomatic and there is no evidence of enlargement of the aneurysm [5].

Changing trends in causalgia.

The term causalgia as currently understood encompasses a wider range of post-traumatic disabilities than Mitchell's original definition as burning pain. In this series, orthopedic injury replaced penetrating trauma as the most common initiating event. Injury to a peripheral nerve may be ill-defined or absent. Serious disability may arise from what appears to be a minor injury. When causalgia is recognized and appropriate therapy instituted, nearly all patients improve.

The use of lyophilized vein grafts in vascular access for chronic hemodialysis.

The feasibility of utilizing lyophilized veins for creation of A-V fistulas was examined in two studies. In Study I, the longevity of lyophilized vein fistulas was found to be comparable to that of fresh veins in the experimental animal. Study II showed that lyophilized cadaveric veins performed at least as well as bovine grafts when used for vascular access in chronic hemodialysis patients. The advantages of lyophilized veins for creation of A-V fistulas in dialysis patients are described.

Operative management of chronic coccidioidomycosis.

Nine of fourteen patients with chronic coccidioidomycosis were treated operatively for therapeutic and diagnostic indications. Complications were minimal and no reactivation or spread of the disease resulted. This series emphasizes the role of the surgeon in the diagnosis and management of chronic coccidioidomycosis and demonstrates the need for the surgeon to be familiar with its natural history and diverse presentations.

Renal artery false aneurysm. An unusual complication of prosthetic patch angioplasty.

False aneurysm formation in a twenty-nine year old black woman treated for renovascular hypertension secondary to fibromuscular hyperplasia by knitted Dacron prosthetic patch angioplasty is reported. Etiologic mechanisms are discussed. The most likely factors leading to false aneurysm formation in this patient are disproportionate compliance between the arterial wall and the prosthesis and increased rigidity of the prosthesis, associated with increased shearing and vibratory stress. This patient was treated successfully by resection of the prosthetic path and involved artery with end-to-end reanastomosis of the artery.

The challenge of arteriovenous fistula formation following disk surgery: a collective review.

Five cases of arteriovenous fistula formation are added to the 68 found in previous reports. A review of the English-language literature revealed that the L4-5 disk space was most frequently involved, the right common iliac artery injured most often, and the right and left common iliac veins and inferior vena cava injured with similar frequency.