Iatrogenic vascular injuries from percutaneous vascular suturing devices.

OBJECTIVE: The purpose of this study was to examine the patterns of injury and the strategies of surgical repair of iatrogenic vascular injuries from a percutaneous vascular suturing device after arterial cannulation. METHODS: We retrospectively reviewed the clinical experience from an academic vascular surgical practice over a 2-year period. The subjects were patients undergoing vascular repair of iatrogenic vascular injury after deployment of a percutaneous vascular suturing device. Interventions were direct repair of arterial injury (with or without device extraction) or arterial thrombectomy and repair. The main outcome variables included patterns of arterial injury, magnitude of arterial repair, limb salvage, hospital stay, and perioperative mortality and morbidity rates. RESULTS: From August 1998 through August 2000, eight patients (4 men, 4 women; median age, 55 years; range, 44-80 years) required vascular operations for complications of percutaneous suturing devices after diagnostic (2) or therapeutic (6) arteriograms through a transfemoral approach. Complications included four pseudoaneurysms (1 infected) due to arterial tear from suture pull through, two entrapped closure devices due to device malfunction, and two arterial thromboses due to narrowing/severe intimal dissection. All patients required operative intervention. Direct suture repair with or without device removal was performed in five patients, arterial debridement with vein patch angioplasty in one patient, and arterial thrombectomy and vein patch angioplasty in two patients. There were no perioperative deaths. The median hospital stay was 5 days (range, 2-33). Limbs were salvaged in all patients with a mean follow-up of 4.8 months (range, 1-13). CONCLUSIONS: Although abbreviated postangiography recovery periods and early ambulation have motivated the widespread use of percutaneous suturing devices, the infrequent occurrence of vascular injuries produced by these devices can be significantly more challenging than simple acute pseudoaneurysms or hemorrhage. In addition, thrombotic complications have a small but finite risk of limb loss.

Repair of aortobronchial fistula using extraanatomic grafts and hypothermic arrest.

Aortobronchial fistula is a rare complication of thoracic aortic operations that is fatal if not promptly diagnosed and repaired. The case of a 23-year-old woman who presented with an aortobronchial fistula after three previous left thoracotomies for thoracic aortic procedures is described.

Stroke rate is markedly reduced after carotid endarterectomy by avoidance of protamine.

PURPOSE: Postoperative neurologic injury remains a significant risk of carotid endarterectomy. Mechanisms include embolization of debris and formation of thrombus on the newly endarterectomized surface. We hypothesized that the risk of postoperative neurologic injury would be lower in those patients who did not receive protamine for reversal of heparin anticoagulation. METHODS: We reviewed 348 consecutive primary carotid endarterectomies performed since January 1, 1986, to determine the relationship between surgical outcomes and reversal of heparin anticoagulation. Patients undergoing additional simultaneous cardiovascular procedures were excluded. One hundred ninety-three patients received protamine after completion of the endarterectomy. The remaining 155 patients did not receive any protamine. RESULTS: All patients in both groups survived to discharge. There were no strokes in those patients who did not receive any protamine; however, the stroke rate in the protamine group was 2.6% (5 of 193), p < 0.045. The incidence of hematoma requiring reexploration was 1.0% (2 of 193) and 1.9% (3 of 155) in the protamine and no-protamine groups, respectively (p = NS). Intraoperative shunting was used more frequently in the no-protamine group (84% vs 67%, p < 0.001), and patch angioplasty was performed more frequently in the protamine group (35% vs 15%, p < 0.001). However, neither shunting nor patching significantly influenced stroke rates. CONCLUSIONS: We conclude that carotid endarterectomy without reversal of heparin anticoagulation is associated with a reduced postoperative stroke rate without a significant increase in morbidity rates.

Risk factors and screening techniques in 500 patients with benign and malignant colon polyps. An urban community experience.

The authors have reviewed 13 years of experience with 500 patients who had 1240 polypoid lesions identified at colonoscopy. An analysis of these patients' symptoms, signs, and past histories prior to initial colonoscopy were collated by computer in order to provide useful information to help in early identification of patients with polyps and to define specific risk factors in patients with polypoid cancers (71 patients with 79 cancers). This study shows that the 500 patients with colon polyps, with and without cancer, are similar in all parameters measured. Their symptoms correlated poorly with the pathology or location of the polyp. Frequently unrelated symptoms brought the patient to the attention of their private physician. A significant high-risk group of patients identified were those with prior colon polyps and cancer. A positive family history of colon cancer was not common. Barium enema, the most common examination, was performed in 90 percent of patients and was the first test to diagnose polyps in 54 percent. Flexible sigmoidoscopy, only more recently available and performed in 20 percent of the patients, established a diagnosis of polypoid disease 96 percent of the time. This study supports screening for all adults above 40 years of age with flexible sigmoidoscopy and stool occult blood.

Review of recurrent polyps and cancer in 500 patients with initial colonoscopy for polyps.

Five hundred patients with 1240 polyps removed by colonoscopy and polypectomy over a 13-year period are the subject of ongoing follow-up study. Ninety-three percent of the patients have been followed an average of 53 months with a recurrence rate of polypoid disease in 26 percent, of which approximately 7 percent demonstrated malignant changes. This compares to a rate of 7 percent metachronous cancer in patients with a malignancy demonstrated at any time in the past. The highest risk group for recurrence are patients with more than four polyps at initial colonoscopy, with a 59 percent recurrence rate. The following recommendations for follow-up are made: 1) Flexible sigmoidoscopy is adequate yearly follow-up if the original polyps are confined to the rectum and sigmoid. 2) Colonoscopy should be carried out the first year if the original polyps are beyond the rectum and sigmoid, and yearly until the colon is cleared of recurring lesions. 3) Colonoscopy is indicated in patients with cancer before surgery if possible; if not, within six months after resection. 4) Interval six-month examinations are indicated in patients with colon cancer and multiple synchronous polyps until the colon is cleared. 5) Large, sessile polyps resected piecemeal require a three-month follow-up until gone. 6) When the above conditions are met, colonoscopy at three-year intervals is adequate for long-term follow-up of neoplastic polyps to detect and prevent early malignancy.

A method for the microinjection and culture of protoplasts at very low densities.

A method has been developed which allows the recovery of calli from a high proportion of individual, injected, mesophyll protoplasts of Nicotiana tabacum c.v. Xanthi. A small drop of low melting point agarose is used both to hold protoplasts during microinjection and for their subsequent culture in feeder dishes. The feeder dishes consist of "beads" of protoplasts at a high density set in agarose to "feed" the infected protoplasts across a liquid medium.The method has been used successfully both with normal protoplasts and protoplasts from which the vacuole has been removed.