Catastrophic Antiphospholipid Syndrome after Orthotopic Liver Transplant.

Background: Catastrophic antiphospholipid syndrome (CAPS) is an autoimmune thrombogenic disorder of small and large vessels caused by autoantibodies against phospholipids and phospholipid-binding proteins. This severe form of antiphospholipid syndrome (APS) presents clinically with simultaneous life-threatening multiorgan thrombosis and the presence of two or more persistent antiphospholipid antibodies (APL) confirmed on testing 12 weeks apart. Case Presentation. We describe a case report of a 66-year-old woman with detected antinuclear antibodies (ANA) pretransplant diagnosed with CAPS following orthotopic liver transplant. The patient had acute respiratory failure; Doppler ultrasound and CT angiogram confirmed thrombosis in the hepatic artery, subsequent occlusion of the jump graft, and a splenic infarct. Hypercoagulability workup showed elevated levels of anticardiolipin IgG and beta-2-glycoprotein IgG/IgM and positive lupus anticoagulant, treated with steroids and anticoagulation. The patient was discharged after one month and was transitioned from heparin to life-long warfarin. Conclusion: Our patient provided a standard presentation of CAPS with abnormal pretransplant levels of antinuclear antibodies (ANA). Although there have been studies investigating the relationship between anticardiolipin antibodies and lupus anticoagulants and APS, the relationship between pretransplant positive ANA or antimitochondrial antibodies (AMA) and CAPS has yet to be explored. Further studies will be needed to determine the significance of these antibodies. We recommend preoperative APL testing for patients with positive ANA and AMA at preliver transplant presentation.

The impact of direct-acting antiviral agents on liver and kidney transplant costs and outcomes.

Direct-acting antiviral medications (DAAs) have revolutionized care for hepatitis C positive (HCV+) liver (LT) and kidney (KT) transplant recipients. Scientific Registry of Transplant Recipients registry data were integrated with national pharmaceutical claims (2007-2016) to identify HCV treatments before January 2014 (pre-DAA) and after (post-DAA), stratified by donor (D) and recipient (R) serostatus and payer. Pre-DAA, 18% of HCV+ LT recipients were treated within 3 years and without differences by donor serostatus or payer. Post-DAA, only 6% of D-/R+ recipients, 19.8% of D+/R+ recipients with public insurance, and 11.3% with private insurance were treated within 3 years (P < .0001). LT recipients treated for HCV pre-DAA experienced higher rates of graft loss (adjusted hazard ratio [aHR] 1.34 1.852.10 , P < .0001) and death (aHR 1.47 1.681.91 , P < .0001). Post-DAA, HCV treatment was not associated with death (aHR 0.34 0.671.32 , P = .25) or graft failure (aHR 0.32 0.641.26 , P = .20) in D+R+ LT recipients. Treatment increased in D+R+ KT recipients (5.5% pre-DAA vs 12.9% post-DAA), but did not differ by payer status. DAAs reduced the risk of death after D+/R+ KT by 57% (0.19 0.430.95 , P = .04) and graft loss by 46% (0.27 0.541.07 , P = .08). HCV treatment with DAAs appears to improve HCV+ LT and KT outcomes; however, access to these medications appears limited in both LT and KT recipients.

Incidence and clinical significance of iliac vein compression.

OBJECTIVES: To determine the frequency of left common iliac vein (CIV) compression by the right common iliac artery (CIA) based on CT scan images. METHODS: CT scan images were reviewed and the diameter of CIV was measured at the area of minimal diameter and compared to the distal adjacent segment and the contralateral CIV at the same level. Medical records were reviewed for symptoms, deep vein thrombosis (DVT) and risk factors that might be associated with DVT. Data were analyzed with SPSS program using both Chi square and t test. A p < 0.05 was considered statistically significant. Linear regression (R2) was used to evaluate correlation. RESULTS: A total of 300 complete records were reviewed. The mean age was 51.89 years, with 126 (42%) males. Comparison between the two groups (>70% vs <70%) showed similar clinical factors such as history of DVT, surgery, immobilization, malignancy, limb trauma, pregnancy, obesity, CHF, and smoking. There were more females with CIV compression of 70% or more than males (19.5% vs 11.1% P < .049). CONCLUSION: Diameter stenosis more than 70% was present in 30.6% of cases with higher incidence in females. The presence of stenosis was not associated with the presence of clinical symptoms.

Celiac artery compression syndrome: a radiological finding without clinical symptoms?

The aim of the paper is to determine the incidence of celiac artery compression (CAC) based on computed tomography (CT) scan and correlate the findings to the clinical presentation of patients presenting for CT scan in a hospital. Abdominal CT scans of patients were reviewed between September 2010 and November 2010. CAC was diagnosed if the celiac axis appeared to have a hook or U-shaped appearance with stenosis. The medical records of the patients were reviewed for gastrointestinal symptoms (abdominal pain, nausea, vomiting, constipation, diarrhea), as well as food fear and weight loss. Patients with CAC had lower incidence of symptoms compared with those without CAC (42.1 versus 65.3%, P = 0.042). A total of 450 patients were evaluated. In the end, 284 had both complete medical records and CT scans. The mean age for all patients was 51.3 ± 1.2 years. There were 124 men (42.6%) and 160 (57.4%) women. Nineteen (6.7%) patients had radiological evidence of CAC. CAC is not an uncommon CT finding in patients presenting for CT scan.

Stent fracture in the brachiocephalic trunk.

Stents are commonly used as a tool for revascularization of different vascular beds in the body. However, many pitfalls have been reported with their use, such as thrombosis, migration, restenosis or fractures. The latter have been strongly correlated to in-stent restenosis with long-term follow-up. We report a rare case of an early stent fracture in the brachiocephalic trunk with in-stent restenosis and recurrence of symptoms. To our knowledge there has been only one case report of a delayed brachiocephalic stent fracture in the English literature. We believe that our case is the first report of an early stent fracture in the brachiocephalic trunk.

Brucellosis presenting as myelofibrosis: first case report.

We describe the case of a 29-year-old woman who presented with pancytopenia and myelofibrosis. Brucella melitensis was identified in her blood. The patient recovered completely with doxycycline and rifampin. A repeat bone marrow biopsy showed hypercellularity without myelofibrosis. Bone marrow findings in cases of pancytopenia due to brucellosis reveal normocellularity, hypercellularity, hemophagocytosis, or granuloma. To our knowledge this is the first report of brucellosis causing myelofibrosis. Brucellosis should be considered as a possible cause of myelofibrosis in endemic areas.

Stroke rehabilitation: application and analysis of the modified Barthel index in an Arab community.

PURPOSE: The primary aim was to provide experience with a functional evaluation instrument (modified Barthel index MBI) that assures the quality of work and identify its deficiencies, familiarize our staff with the feasibility of its application on our local inpatients and educate our personnel in the field of stroke rehabilitation. The secondary aim was to collect data that are measurable and reproducible, identify specific local factors that adversely affect outcomes and serve as a feedback system to our national organizations. METHODS: In this prospective/retrospective study we evaluated 80 hemiplegic patients with completed stroke, admitted to hospital during the year 1989 1990. They were assessed by a neurologist, physiatrist and physiotherapist on admission and discharge using the MBI. All patients received comprehensive inpatient rehabilitation. The study was interrupted at the beginning of the Gulf crisis. However, the data were revived and retrospectively studied in the year 1994-1995. RESULTS: The MBI proved to be fully acceptable and easily applicable in our community. The rehabilitation staff became rapidly familiarized with its application and the reproduction of its data. The goals of rehabilitation were achieved through the reduction in the number of individuals in the more severe MBI scores and the increase in the number of individuals in the less severe ones. Significant improvements occurred in dressing of the upper and lower body, washing, grooming, care of perineum, transfer chair, toilet and walking on a level of 50 yards (p < or = 0.0005). CONCLUSIONS: We conclude that MBI is simple, convenient, efficient, gives exact and accurate information about daily activities and ambulation and could be used in inpatient follow up sittings, in the Arab and culturally similar Middle East countries.

Contralateral internal jugular vein interposition for salvage of a functioning arteriovenous fistula.

Outflow obstruction in patients with hemodialysis access can cause venous hypertension and jeopardize the patency of the access site. Numerous surgical procedures have been described to decompress an occluded subclavian vein. In this report, we describe the use of the contralateral internal jugular vein as a bypass conduit to decompress an occluded brachiocephalic vein in a patient whose dialysis was dependent on this vein access.

Cricopharyngeal myotomy in neurogenic oropharyngeal dysphagia.

OBJECTIVE: Cricopharyngeal myotomy as an independent procedure has been performed on fourteen patients with a variety of neuromuscular disorders, suffering from neurogenic oropharyngeal dysphagia in the interval between 1994-1997. All of them were referred from a neurophysician or physiatrist after failure of improvement by medical treatment. METHODS: The selection of patients for operation was based mainly on clinical evaluation and simple exclusion criteria without manometric studies. RESULTS: There was dramatic improvement in twelve, with recurrent laryngeal nerve palsy and temporary pharyngeal fistula in two patients. No mortality was recorded. CONCLUSION: We conclude that cricopharyngeal myotomy is a simple, safe and effective procedure with acceptable morbidity. It should be considered as a rehabiliation procedure for patients with dysphagia due to various neurologic disorders based on simple, clinical exclusion criteria without the need for the tedious, time consuming and expensive manometric studies.

Nd Yag laser angioplasty: a safe procedure in peripheral vascular surgery.

BACKGROUND: Thirty-three patients (34 limbs) with peripheral vascular occlusive disease were treated with Nd Yag laser assisted angioplasty over a three-year period (1989-1991). METHODS: Sixteen males and 17 females were included in the study. The mean age of all patients was 70.29 (44-86) years. Twenty-two (66.7%) patients were smokers, 21 (63.6%) had coronary artery disease and 14 (42.4%) had diabetes mellitus. Thirty-three patients (100%) had disabling intermittent claudication, 20 patients (60.6%) had rest pain, 2 patients (6.1%) had ulcers and 10 patients (30.3%) had gangrenous changes. Thirty-nine vessels were treated; 34 (87.2%) superficial femoral arteries, 4 (10.3%) popliteal arteries and 1 external iliac artery. Eleven (28.2%) vessels were totally occluded and the remaining 28 (71.8%) vessels had high grade stenosis of more than 90%. The mean preoperative ABI Index was 0.23+/-12. RESULTS: The preoperative angiogram showed poor out-flow in 24 (70.6%) extremities, 1 patent distal vessel in 7 extremities (20.6%) and at least 2 vessels in 3 extremities (8.8%). The patients were followed up for a period of 9.9 months (20 days-30 months). The procedure could not be done in 2 extremities. All the remaining 32 extremities had patent vessels at the end of the procedure. Fifteen (48.4%) patients stated that they improved but remained symptomatic. Twelve (38.7%) were completely asymptomatic, 3 (9.7%) patients had no change in their symptoms and 2 patients worsened at the end of the follow-up period. The mean postoperative ABI was 0.78. Bleeding from the puncture site requiring closure was the most common complication of the procedure in 6 patients (19.4%). Angioplasty in 5 of these patients was done by the open technique. Other complications included hematoma in 3 (9.7%) patients and one case (3%) of artery perforation. Among those who remained asymptomatic at the end of the follow-up period the mean change in ABI was 0.625+/-0.19, those who improved but remained symptomatic the mean ABI change was 0.43+/-0.25 while those whose symptoms did not change or worsened the mean ABI change was 0.12+/-0.13. The ABI change in the first two groups was significantly higher than the last one (p<0.006 and p<0.001 respectively). There was no significant difference in the outcome of LABA between stenosed and occluded vessels. Smoking was significantly higher in the symptomatic patients (7/20) compared to those who were asymptomatic 5/12, p<0.02. Diabetes mellitus, cardiovascular disease and the preoperative ABI were not significant variables in the outcome of angioplasty. CONCLUSIONS: In conclusion, Nd Yag laser assisted angioplasty is a safe procedure. It could relieve symptoms in 87.1% of cases. Change in the ABI and smoking are predictive of the success of the procedure.

A comparative evaluation of femorofemoral crossover bypass and iliofemoral bypass for unilateral iliac artery occlusive disease.

The purpose of this study was to compare the results of extra-anatomic femorofemoral crossover bypass grafting to the anatomic iliofemoral bypass grafting procedure in the treatment of patients with unilateral iliac artery occlusive disease with respect to patency and limb salvage. The records of all patients with unilateral iliac artery disease who underwent revascularization between January 1988 and December 1995 at the University of Iowa Hospitals and Clinics (UIHC) were retrospectively reviewed; 108 patients were identified and divided into two groups. Group I (n=68; male/female=44/24) was composed of all patients who underwent a femorofemoral crossover extra-anatomic bypass. All patients who underwent an iliofemoral anatomic bypass constituted group II (n=40; male/female=24/16). The mean age for group I was 60 years (range 28-87) and for group II, 54 years (range 14-86). The medical risk factors between both groups were comparable. Except for the higher incidence of gangrene in group II the indications for surgery were comparable between both groups. A polytetrafluoroethylene graft was used in 88% of group I patients and in 90% of group II patients (NS). In the remaining patients, an autogenous vein conduit was used. Two patients from group I (2.9%) died in the perioperative period (NS). Graft patency was assessed by clinical evaluation, Doppler-derived ankle/brachial indices, and color duplex imaging. The cumulative primary and secondary patency rates, limb salvage, and patient survival were calculated by use of life table analysis (SE<0.1). The need for simultaneous outflow and inflow procedures at the time of surgery was comparable between both groups. The proportion of patients who underwent further revascularization during follow-up was also comparable. The 5-year primary and secondary graft patency rates were 81.7% and 90.3%, in group I and 61.3% and 80.5% in group II. Although the difference between both groups was not significant there was a tendency toward higher rates with femorofemoral bypass. The 5-year survival rates of 80.3% for group I and 73.3% for group II were comparable. These data suggest that there is no significant difference in the long-term results between the femorofemoral crossover bypass grafts and iliofemoral grafts. Both procedures result in acceptable patency and limb salvage rates. The femorofemoral bypass is, however, more attractive, for it can be performed under local anesthesia if needed and does not involve the creation of the retroperitoneal incision necessary with the iliofemoral bypass.

Entering the ninth decade is not a contraindication for carotid endarterectomy.

The role of carotid endarterectomy (CEA) in stroke prevention is now better defined. However, its role in patients older than 79 years of age is controversial. This group of patients has been excluded in most clinical trials. In this study the authors reviewed their experience with CEA patients >79 years old. The records of all patients older than 79 years of age who underwent a CEA in a recent time period from January 1988 to December 1996 were retrospectively reviewed. Forty-one patients (31 men, 10 women) were identified by computer search. The indication for operation included transient ischemic attack in 12 (29.3%), amaurosis fugax in nine (22%), stroke in two (4.9%), and nonhemispheric symptoms in three (7.3%). Fifteen patients (36.6%) were asymptomatic. Medical risk factors included coronary artery disease in 26 (63.4%), hypertension in 22 (53.7%), and smoking in 12 (29.3%). The procedure was performed under EEG monitoring in all patients. General anesthesia was administered in 37 (90%) and regional anesthesia in four (10%). Shunts were used in four (10%) patients. The internal carotid artery was patched in 16 patients (39%). One patient (2.4%) developed a perioperative stroke and only one patient developed perioperative myocardial infarction (MI). None of the patients died within 30 days of surgery. In addition to the one MI case, five patients developed minor complications. The average length of time for stay after CEA was 3.4 days. Patients were followed up for an average of 20.7 months. Six patients died during follow-up. Four of those died from an MI and two from a stroke. The authors conclude that with proper selection of patients, CEA is safe in the octogenarian. Age alone should not be a contraindication for CEA.

Internal iliac revascularization during aortic aneurysm replacement: a review and description of a useful technique.

The coexistence of infrarenal aortic aneurysm and internal iliac artery aneurysm may represent a management problem with regard to preservation of the pelvic blood supply. In this article, we review the methods available for maintaining the pelvic blood flow and describe a useful technique that we have successfully utilized in seven patients to preserve the hypogastric artery blood flow.

Is color duplex surveillance of infrainguinal polytetrafluoroethylene grafts worthwhile?

BACKGROUND: Unlike vein bypasses, the role of duplex surveillance of infrainguinal prosthetic bypass grafts is controversial. The purpose of this study was to evaluate the adequacy of color duplex surveillance in identifying failing infrainguinal polytetrafluoroethylene (PTFE) bypass grafts and to assess its value in predicting continued bypass patency. METHOD: The surveillance data of primarily patent PTFE bypass grafts were compared with those of revised/occluded PTFE grafts. Ninety-five patients underwent 102 infrainguinal PTFE bypass grafts from January 1991 to December 1996 and were enrolled in a duplex surveillance program at 1 month postoperatively, every 3 months in the first year, every 6 months in the second year, and yearly thereafter. RESULTS: Seventy grafts remained primarily patent, 5 were revised and 27 occluded. There was no significant difference in the mean age, gender, indication for surgery, type of original procedure, or duration of follow-up between both groups. Four hundred and seven duplex surveillance data were available for analysis. Focal increase in peak systolic velocity (PSV) 3 x the adjacent segment or low flow manifested by PSV <45 cm/sec were considered abnormal. In the primarily patent group, 5 bypasses had abnormal duplex surveillance and were found to have no abnormality on angiogram and remained patent during the study period. In the revised/occluded group, duplex surveillance was abnormal in 8 bypasses. Twenty-four bypasses occluded without any predicting abnormalities on their last duplex examination, which was performed within 3 months from the occlusion in the majority of the patients. In the 27 occluded bypasses, no intervention was necessary following the occlusion in 7 grafts because of mild or no symptoms. Two patients were treated with a primary amputation and 2 had new bypasses. In 16 occluded grafts, salvage of the PTFE bypass was attempted. Ten of these grafts were patent at the end of the follow-up. The sensitivity of duplex surveillance was 25% with a positive predictive value of 61.5%. CONCLUSION: Duplex surveillance of infrainguinal PTFE bypass grafts has a low yield and is inadequate at predicting continued bypass patency.

Renal hilar Doppler analysis is of value in the management of patients with renovascular disease.

BACKGROUND: An increasing interest in the role of Doppler ultrasound and duplex scan in screening for renovascular hypertension has recently been noted. We conducted this study to define the role of renal hilar Doppler ultrasound (RHDU) in evaluating renal artery stenosis and its value in the postoperative follow-up after renal revascularization. METHODS: One hundred and fourteen patients are included in this study with a mean age of 63.7 (11 to 89) years. Seventy-two patients underwent renal revascularization. The most frequent revascularization procedure was renal artery bypass in 82%. The RHDU results were compared with 130 angiograms done within 1 month of the RHDU study. The Doppler velocity signal in a segmental artery in the renal parenchyma was recorded, and the waveform was analyzed. An acceleration index (AI) less than 3.78 KHz/sec/MHz and an acceleration time (AT) greater than 0.1 seconds were used to indicate the presence of a significant renal artery stenosis. RESULTS: The overall technical success rate of all RHDU studies was 93.5%. The AI value was higher in the group of patients with normal renal arteries than those with a stenosis (4.7 +/- 1.4 KHz/sec/MHz versus 1.23 +/- 1.13 kHz/sec/MHz, respectively, P <0.0001), and the AT was lower in the former group compared with the latter (0.052 +/- 0.011 sec versus 0.122 +/- 0.069 sec, P <0.0001). The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy for AI were 89%, 92%, 85%, 94%, and 92%, respectively; and for AT were 62.5%, 97.5%, 91%, 86.5%, and 87% respectively. There was a significantly high agreement between the AI and AT results and those of arteriography (Kappa of 0.82 and 0.66, respectively, P < 0.0001). There were 10.6% kidneys with multiple renal arteries by arteriography. In these kidneys the accuracy was lower for both AI and AT and the agreement with arteriography was nonsignificant. In the postoperative period the accuracy of RHDU was 86% for AI and 95% for AT. CONCLUSIONS: Renal hilar Doppler ultrasound has a high accuracy and agreement with arteriography in the diagnosis of renal artery stenosis. Its value is limited by the presence of multiple renal arteries, renal artery occlusion, and high incidence of postoperative false-positive results. It can be useful as a noninvasive screening test for patients suspected of having renal artery stenosis and for surveillance following renal revascularization.

Laparoscopic appendectomy: a viable alternative approach.

Laparoscopic appendectomy (LA) is relatively a new technique and requires comparison to open appendectomy (OA) to determine the more favorable approach in the surgical management of acute appendicitis. We designed this study to compare the course and postoperative complications between LA and OA. We reviewed the charts of both groups of patients and followed their course in the hospital. Seventy-seven patients who underwent LA with one conversion to the open technique (1.3%) were compared to 84 patients who underwent OA. There was no difference in age and sex distribution. The mean hospital stay was shorter in the LA (32.5+/-10 vs 74.2+/-24 h, p < 0.0001). Parenteral analgesia requirement was higher in the OA group (4.7+/-1.4 vs 2.6+/-2, p < 0.0001). The total cost was higher in the OA group ($11,260+/-4000 vs 7,090+/-3500, p < 0.05). There was no significant difference in the OR time, duration of the procedure, and surgery costs between both groups. Normal appendices removed were similar in both OA and LA groups (23.8 vs 28.9%). There was no difference in the rates of postoperative complications between both groups. We conclude that LA is a viable alternative to OA. It is safe, cost effective, and less invasive than the OA with less pain and shorter hospital stay.

Spontaneous duodenal perforation in neonates: a case report and review of literature.

Although duodenal perforation in neonates is an extremely rare entity, it should be suspected in any case with signs of viscus perforation. If found in the absence of possible causes, duodenal perforation is considered to be spontaneous. It is believed to be of multifactorial origin. Once found primary closure with or without omental patching is the treatment of choice. In this article we describe one case of spontaneous perforation and analyze the possible causes.

Preoperative administration of antibodies against tumor necrosis factor-alpha (TNF-alpha) and interleukin-1 (IL-1) and their impact on peritoneal adhesion formation.

This study investigates the effects of preoperative intravenous administration of antibodies against TNF-alpha and IL-1 on peritoneal adhesion formation. Fifty-six Sprague-Dawley rats (350-400 gm) were used in this study. Eight rats were used to empirically determine the amount of anti TNF-alpha and anti IL-1 needed for complete in vivo neutralization. This amount was used for preoperative treatment of selected groups. Forty-eight rats were divided into four equal groups (n = 12). All rats underwent a midline laparotomy. Ten cm square of cecal serosa was abraded, the peritoneal cavity was irrigated with normal saline, and the incision was closed in layers. Cultures were obtained intraoperatively and rats with positive cultures were excluded. Rats in Group 1 were not treated (control), while rats in Groups 2, 3, and 4 were treated with anti TNF-alpha, anti IL-1, and a combination of anti TNF-alpha and IL-1 respectively. All rats were killed at 3 weeks, and peritoneal adhesions were graded using a scale of 0 (none) to 3 (extensive, dense). Rats treated with anti IL-1 (Group 3) and those treated with a combination of anti TNF-alpha and anti IL-1 (Group 4) had significantly fewer adhesions when compared with Group 1 (control) (P < 0.01 and < 0.005, respectively). Least adhesion formation was associated with Group 4 rats. In conclusion, selective immunosuppression, at a molecular level, appears to have a significant impact on rates of postoperative peritoneal adhesion formation.

Tumor necrosis factor-alpha: a marker for peritoneal adhesion formation.

This study investigates the possible correlation between higher levels of tumor necrosis factor-alpha (TNF-alpha) and higher rates of adhesion formation following standard bowel injury. Forty-five Sprague-Dawley rats were divided into three equal groups. Blood was obtained from all rats preoperatively. All rats were subjected to a laparotomy. In group 1 the peritoneal cavity was irrigated with normal saline. In group 2 the cecal serosa was abraded, while rats in group 3 had 2 cm of their small bowel resected. A peritoneal catheter was placed in all rats prior to closure. Blood samples were obtained at 30, 90, and 180 min following injury. Peritoneal exudate (PE) was collected and the catheter removed in 3 hr. Blood samples and peritoneal exudate were processed and levels of TNF-alpha were determined. The severity of adhesions was graded 3 weeks postoperatively using a score of 0 (absent) to III (extensive, dense). Histological evaluation for collagen deposition and fibroblasts was carried out. Rats in group 1 had significantly lower adhesion grades when compared to groups 2 and 3 (grade 0; P < 0.0001). Postoperatively, groups 2 and 3 had higher serum and PE TNF-alpha levels when compared with group 1 (P < 0.01). There was a significant correlation between higher grades of adhesions and higher levels of serum and PE at 30, 90, and 180 min following operation (P < 0.01 and < 0.05, respectively). TNF-alpha, a proinflammatory cytokine, appears to be a good biological marker for postoperative intraabdominal adhesion formation.