Adventitial cystic disease of the femoral vein: a case report and review of the literature.

Painless edema of the left leg developed in a 65-year-old man without a history of venous disease, and he was found to have a mass compressing the lumen of the left common femoral vein. The intramural cyst was drained through transvenous exposure and found to contain mucoid material. This is the seventh case of adventitial cystic disease of a vein in the world literature. Analogous to adventitial cystic disease of arteries, it is defined by venography, CT scanning, and duplex ultrasonography. Surgical drainage is the treatment of choice.

Local anesthesia for surgery on the foot: efficacy in the ischemic or diabetic extremity.

The efficacy, risks, and benefits of the use of local anesthesia for surgery on the foot were assessed in 75 patients who underwent 127 procedures with lower calf, ankle, metatarsal-ray, and digital blocks. There were 23 procedures on digits alone, 97 forefoot operations (transmetatarsal amputations, wound debridements, closures, osteotomies, joint resections), six ankle or hind-foot amputations, and one open ankle disarticulation. There were no complications directly related to the use of local anesthesia; specifically, no extension of preexisting infection or ischemia due to injection in the foot. There were three deaths (30-day mortality 4%). The procedures were uniformly well tolerated, even in patients with ongoing myocardial ischemia or severe metabolic disorders. Local anesthesia is a safe and effective method to perform local debridement or amputation of the foot in an ischemic or diabetic extremity.

Acute arterial insufficiency of the male genitalia.

Three patients developed severe ischemia of the penis or scrotum from acute arterial occlusion. In one case, nonhealing ulceration of the glans developed after atheroembolism to the dorsal penile artery. One patient had penile ischemia after ligation of pelvic and femoral collateral circulation during repair of an aorto-bilateral-iliac artery aneurysm. A third patient had ischemia of the penis and scrotum from thromboembolism to the iliac arteries during repair of an aortoenteric fistula. Only seven patients have been described with acute arterial occlusion and severe ischemia of the male genitalia. A rare phenomenon because of rich collateral circulation, acute ischemia of the genitalia nevertheless must be recognized as a sign of severe vascular disease and a consequence of major arterial ligation or occlusion in the pelvis and groins.

Treatment of abdominal aortic aneurysm by exclusion and bypass: an analysis of outcome.

Abdominal aortic aneurysm is conventionally treated by aneurysmorrhaphy with inlying graft. Alternatively, division of the aorta, with suture closure of the distal aorta and outflow vessels (exclusion of the aneurysm), and end-to-end proximal to distal bypass may be performed. However, the long-term fate of this operation has not been determined. Specifically, concern exists that the excluded blood filled aneurysm may not thrombose or may be the source of late sepsis. During an 8-year period we have treated 280 abdominal aortic aneurysms (urgent and elective) by exclusion of the abdominal aortic aneurysm sac and bypass via the posterolateral retroperitoneal approach. Mean age was 70 years (range, 44 to 88), with 217 men and 63 women. Preoperative CT scanning and aortography were performed to assess arterial anatomy. Seventy tube grafts and 260 bifurcation grafts were used. Thirty-day mortality rate was 4%. Estimated blood loss was 731 +/- 52 ml; mean transfusion requirements were 456 +/- 82 ml. The minor complication rate was 6%, and it is of great interest that there were no cases of ischemic colitis requiring colectomy. Aneurysm sacs thrombosed except in two anticoagulated patients who required further treatment. No late infections occurred. Five-year bypass patency rate was 98%. These data demonstrate that this method of treatment effectively minimized operative dissection and blood loss and therefore is a viable alternative for the management of abdominal aortic aneurysms.

The effect of flow on the interaction of isolated megakaryocytes with subendothelial extracellular matrix.

We have previously shown that human, guinea pig, or rat megakaryocytes, incubated under static conditions on an extracellular matrix (ECM) produced by endothelial cells, readily adhered to the matrix and underwent platelet-like shape change and thromboxane A2 secretion. We have now exposed megakaryocytes to ECM in a perfusion system similar to that used to study platelets circulated over aortic subendothelium. We used a continuous flow circuit incorporating a parallel plate perfusion chamber. Megakaryocytes were isolated to high purity from guinea pig marrow by centrifugal elutriation and velocity sedimentation. The cells were introduced into the flowing medium while the surface of an ECM-coated coverslip mounted in the chamber was observed continuously by phase-contrast video microscopy for up to 18 hours. Megakaryocytes from the flowing suspension started to adhere to the ECM within seconds. Significant adhesion occurred over a range of shear rates, from 10 to 190 seconds-1, did not appear above 300 seconds-1 and was greatest at a shear rate of 60 seconds-1. Adhesion to the ECM was specific, since there was no adherence to glass coverslips, glutaraldehyde-fixed ECM-coated coverslips, or to endothelial cells cultured on ECM-coated coverslips. At low shear rates large aggregates of megakaryocytes formed on the ECM surface; these could be detached and washed away by higher shear forces. Megakaryocytes thus acquire, even before platelet formation, an adhesive capacity similar to that of platelets. In addition, a significant fraction of the adherent megakaryocytes underwent elongation and pseudopod formation similar to that seen in marrow sinusoids.

Impact of the presence of orthopedic hardware on technical performance of major amputations.

Metallic prostheses used for joint reconstruction or open reduction of fractures were discovered pre- or intraoperatively during the performance of six above-knee amputations. The prosthesis was found fortuitously before surgery in two cases on the basis of a surgical scar or radiograph of the leg. In four patients, discovery occurred intraoperatively, with adverse impact on the procedure in two cases: more proximal amputation level to allow hip nail removal was necessary in one case, and difficult transection of the prosthesis stem was encountered in one case. Orthopedic prostheses will be found with an increasing incidence in the population undergoing major amputation. As preparation for amputation, a careful review of the patient's history, a search for scars over the leg and hip, and survey radiographs of the leg must be obtained to prevent a surgical mishap caused by accidental discovery of a prosthesis.

Reexploration for thrombosis in carotid endarterectomy.

We reviewed the records of patients undergoing carotid endarterectomy and manifesting either postoperative stroke or thrombosis by oculopneumoplethysmography (OPG-Gee) to analyze the etiology of stroke and to determine the indications for reexploration. Of 900 consecutive elective endarterectomies performed during an 8-year period, 41 patients experienced a perioperative stroke, carotid thrombosis, or both. These patients were subdivided into three groups: group 1, 22 patients with perioperative stroke and carotid thrombosis; group 2, six patients with carotid thrombosis but without symptoms; and group 3, 13 patients with postoperative stroke but no thrombosis. In group 1, 17 patients were reexplored (group 1a), and five were observed without reexploration (group 1b). In group 2, three of the patients were reexplored (group 2a), and the remaining three were observed (group 2b). None of the group 3 patients were reexplored. In group 1a, four (23%) patients awoke from anesthesia with neurological deficits, whereas in group 3, nine (69%) patients awoke with such deficits. Follow-up at 30 days revealed that 76% of group 1a patients demonstrated improvement in symptoms, whereas similar results were seen in only 20% of group 1b patients and 23% of group 3 patients. These trends were maintained throughout the follow-up period of 1-5 years. Those patients who were asymptomatic, group 2, with thrombosis were more likely to have been operated on for asymptomatic carotid stenosis. with thrombosis were more likely to have been operated on for asymptomatic carotid stenosis. Thrombosis was the most common cause of postoperative stroke (63%) in patients after carotid endarterectomy.(ABSTRACT TRUNCATED AT 250 WORDS)

The pulmonary microcirculation of the rat: differential ultrastructural responses of the endothelia to protamine sulfate.

Protamine sulfate is used clinically to reverse the anti-coagulant effects of heparin and in certain cases high protein, non-cardiogenic pulmonary edema develops. In the present study an initial stage of edema formation, namely, interstitial fluid accumulation around partially muscular extra-alveolar microvessels was observed in rats in situ after right ventricular injections of protamine. In addition, the endothelium of these microvessels displayed marked increases in plasmalemmal vesicles; however, disruption of the endothelium was not observed. Further, endothelial vesicle densities were unchanged and perivascular cuffs were not observed in either the nonmuscular extra-alveolar microvessels or the alveolar capillaries. Left ventricular injections of protamine failed to elicit the ultrastructural responses to protamine. Predosing the pulmonary microcirculation with heparin also served to prevent protamine-induced changes in the partially muscular microvessels. If it is assumed that heparin lowers the threshold for protamine-mediated responses in patients who develop edema, inhibition of protamine-induced changes by heparin predosing cannot be explained by the present data. Although evidence of increased endothelial vesiculation in the partially muscular microvessels was obtained, relative contributions of vesicles or of the junctional clefts to efflux from the pulmonary microvessels is not known. Thus, the mechanisms associated with a reduction of endothelial selectivity to macromolecular efflux after protamine administration remain to be defined.

A flow system for the study of shear forces upon cultured endothelial cells.

A parallel plate chamber in a flow system has been designed to study the effects of fluid shear stresses on cells. The system was applied to the study of cultured endothelial cells grown on cover slips which were accommodated in recessed wells in the base plate. Dye injection studies in the chamber indicated laminar flow over the cells. Shear rates measured over the cover slips by an electrochemical technique were found to be linear with flow rate. Laser doppler anemometry showed parabolic profiles between the plates. Endothelial cells subjected to flow showed a correlation between the time required for orientation and the magnitude of the shear stress.

Evaluation of intraoperative arteriography as a routine for vascular reconstructions.

A retrospective analysis of 391 intraoperative arteriograms performed after reconstruction operations on the carotid, aorta and lower extremity vasculature showed the value of incorporating this procedure as a routine only for the last mentioned site. Identification and correction of inadequacies due to technique are possible. Revisions in technique based upon these experiences have significantly diminished their incidence. Routine intraoperative arteriography for revascularization procedures of the lower extremity has further enabled us to classify reliably the runoff and correlate these findings with subsequent graft patency. Late graft closure, predominantly due to progressive or accelerated obliterating atherosclerosis in the distal circulation, occurred almost exclusively within the first year following reconstruction in those patients identified as having poor runoff by intraoperative arteriography. This group, in particular, should be closely monitored by noninvasive physiologic means and even post-operative arteriography to enable either prophylactic or therapeutic correction. In some instances, based upon intraoperative arteriography or subsequent studies, fruitless and potentially harmful reoperative vascular procedures may be obviated.