Femoro-distal bypass surgery at Groote Schuur hospital--4-year retrospective study.

UNLABELLED: An analysis of the demographics and outcome of femoro-distal bypass in patients presenting with defined critical limb ischaemia at Groote Schuur Hospital, Cape Town, is presented. MATERIALS AND METHODS: A retrospective review was conducted between January 1998 and December 2001. During this period, 65 patients underwent femoro-distal bypass. Of these, 57 patients were analysed and 8 patients were excluded from the study because of incomplete medical records RESULTS: The median age of the patients in this study was 62 years, with a male-to-female ratio of 34:23. Twenty-eight patients (49%) were diabetic. An overall 2-year mortality of 19.2% was recorded. Reversed saphenous vein graft (RSVG) was used in 29 legs (50.9%) and in situ vein graft (ISVG) in 19 legs (33.3%). There was no statistically significant difference in the graft patency between the two methods (p = 0.39); the 2-year cumulative patency was 40% for the RSVG and 39% for the ISVG. In our unit only 2 factors influenced the outcome of femoro-distal bypass--local sepsis in the foot and an increased early postoperative ankle-brachial index (p < 0.05). Diabetes mellitus, gender, age and race had no influence on the outcome. This study showed that the site of the distal anastomosis had no effect on graft patency or limb salvage. At 2 years, the cumulative patency and limb salvage rates were 40% and 56% respectively. Of the 11 grafts with stenotic lesions requiring intervention, 6 were detected between 18 and 24 months. CONCLUSION: Management of critical limb ischaemia is a major part of the workload in our unit, with most patients undergoing primary amputation. The surgical outcome of femoro-distal bypass was largely influenced by local sepsis and early postoperative ABI. We found that more than half the stenotic lesions detected during graft surveillance occurred beyond 18 months postoperatively. This suggests that a graft surveillance programme should continue beyond 18 months.

Extravascular axillary vein compression in a competitive swimmer: a case report.

An unusual case of acute axillary vein compression secondary to hypertrophy and intramuscular edema of the subscapularis muscle is described in a competitive swimmer. The signs and symptoms of this condition are similar to those of axillary vein thrombosis, including nonedematous swelling, discoloration, pain, and prominent cutaneous veins of the involved upper limb. Early recognition and diagnosis by means of venography are important to distinguish the condition from axillary vein thrombosis and to alert the practitioner to the potential of future axillary vein thrombosis in such a case. The treatment is primarily conservative.

Abdominal aortic aneurysmectomy in a renal transplant patient.

Standard surgical techniques were modified to allow continued perfusion of a renal allograft during resection of a large symptomatic abdominal aortic aneurysm. Neither hypothermic perfusion nor temporary bypass were employed. No alteration in renal function was observed and the patient remains well. Complex methods of renal allograft protection are probably unnecessary when transplant recipients undergo aortic reconstruction. However simple modifications or technique can substantially reduce renal ischaemic time and further add to the safety of the procedure.

Equilibrium radionuclide angiocardiography prior to elective abdominal aortic surgery.

Equilibrium radionuclide angiocardiography (ERNA) was employed preoperatively in 183 patients undergoing elective abdominal aortic reconstruction to measure left ventricular ejection fraction (LVEF) and to detect abnormal regional wall movement. Abnormal ejection fractions were virtually confined to the 97 patients who had clinical, electrocardiographic or radiographic evidence of heart disease. An operative mortality of 8.7% was recorded. Major cardiac events (defined as myocardial infarction, cardiac failure or malignant ventricular arrhythmia) occurred in 15 of 86 abdominal aortic aneurysm patients (17.4%) and six of 96 (6.25%) patients with aorto-iliac occlusive disease. Patients with an abdominal aortic aneurysm and abnormal LVEF or regional wall motion abnormality were more likely to suffer a cardiac event (p less than 0.001), the event rate exceeding 60% in patients whose LVEF was less than 35%. An abnormal LVEF failed to predict a cardiac event in patients with aorto-iliac occlusive disease. While not indicated in patients lacking clinical evidence of heart disease, ERNA can refine the assessment of cardiac risk, particularly in patients with previous myocardial infarction and define a high risk group in whom aortic reconstruction should be avoided except for the most compelling of indications.

Successful treatment of infected thoracoabdominal aortic graft by percutaneous catheter drainage.

A large perigraft abscess infected with Klebsiella sp. developed around a woven Dacron prosthesis inserted into a patient at high-risk with a leaking thoracoabdominal aortic aneurysm. Percutaneous insertion of a sump drainage catheter under ultrasound guidance accompanied by local and systemic antibiotic therapy was the only reasonable management option. Two years later the patient remains well with no evidence of sepsis on clinical examination, hematologic studies, computerized tomography or indium 111 labeled autologous leucocyte imaging. This technique may be successful in selected high-risk situations.

Postoperative intussusception in adults. A report of 5 cases.

Five cases of postoperative intussusception in adults illustrate the clinical features of this uncommon complication. The diagnosis is usually made at laparotomy after a prolonged period of inappropriate conservative treatment, but can be made radiologically if suspected clinically. Simple reduction is usually effective with no potential for recurrence. Although various theories hav e been proposed and various factors implicated, the precise cause and mechanism in individual patients usually remains unknown.

Pentavalent technetium-99m (V)-DMSA uptake in a pheochromocytoma in a patient with Sipple's syndrome.

This case report describes 99mTc(V)-dimercaptosuccinic acid (DMSA) accumulation in a pheochromocytoma in a patient with Sipple's syndrome. Scintigraphy with 99mTc(V)-DMSA demonstrated uptake in medullary carcinoma of the thyroid gland (MCT). Iodine-131 metaiodobenzylguanidine (MIBG) scintigraphy showed the bilateral pheochromocytomas but did not demonstrate uptake in the MCT.

Portal vein obstruction by ectopic liver tissue.

The causes of portal vein obstruction in children with extrahepatic portal hypertension are variable. We report on a case of portal vein obstruction by ectopic liver tissue in an 8-year-old boy. The ectopic liver had a normal architectural pattern. The clinical management and radiology are reviewed.

Lower limb vein trauma: a long-term clinical and physiological assessment.

The aim of this study was to assess the long-term clinical and physiological sequelae of lower limb venous trauma in a civilian practice. Twenty-six patients who had undergone surgery for lower limb venous trauma (median elapsed time 19.5 months) underwent assessment. Injuries had been sustained to the external iliac, common femoral superficial femoral and popliteal veins in two, four, nine and eleven limbs respectively. Using clinical assessment, photoplethysmography recovery time, the presence of popliteal reflux and venographic evidence of thrombosis, the final outcome was graded as good, fair or poor. Fourteen patients had pedal oedema, including two with a postphlebitic limb. The overall photoplethysmography recovery time (mean and s.d.) was 20.6 (8.7) s in the injured and 32.1 (6.7) s in the non-injured limbs (P = 0.002). Patients with a venographically occluded vein had a shorter photoplethysmography recovery time than those in whom the vein was patent (13.4 (5.6) versus 21.6 (8.7) s; P = 0.07). Popliteal reflux was present in 12 injured limbs. Seven of 12 venograms performed on limbs with a vein repair had evidence of previous thrombosis. Vein ligation carried considerable morbidity and all end-to-end anastomoses initially failed. In retrospect, saphenous vein grafts were too narrow for the recipient veins and panel grafts might have been more appropriate. Overall 11 of 26 patients (42 per cent) had a poor result. The repair of choice is a saphenous vein patch for lesser injuries and a saphenous panel graft for major injuries. Vein ligation should be avoided unless another life-threatening injury demands priority.

Gastric carcinoma in young adults.

Of 720 patients with gastric carcinoma treated over a 6-year period, 37 (5%) were 35 years of age or younger. They differed from older patients in that the usual sex ratio was altered (18 men: 19 women), and in certain histologic features. Poorly differentiated or undifferentiated lesions predominated (34 patients), and the distribution of histologic types was unusual; two thirds each were of the diffuse type (Lauren classification) or signet ring type (World Health Organization classification), and over three quarters were infiltrative (Ming classification). Intestinal metaplasia was absent in the majority of patients, and gastritis was less commonly seen than in older patients. Although most patients had long histories of disease and advanced disease, the TNM stages and the proportion undergoing curative resection (8%) were similar to those seen in older patients. Except for one who has survived 5 years, all patients in this study have died.