Pseudoaneurysm complicating knee arthroscopy.

Pseudoaneurysm formation is a rare complication of knee arthroscopy. Cases reported in the literature have involved the popliteal, superior and inferior medial geniculate, and the inferior lateral geniculate arteries. These cases have all been described as presenting within 2 to 3 weeks of the arthroscopic procedure. Described here are two unique cases, the first a delayed presentation and the second involving the recurrent anterior tibial artery.

Risk assessment in patients undergoing carotid endarterectomy.

Factors that contribute to the outcome of carotid endarterectomy include appropriate patient selection, preoperative medical optimization, meticulous operative technique and postoperative management. This study was designed to evaluate associated medical and operative risk factors with surgical outcomes for 9795 consecutive carotid endarterectomies performed by members of a voluntary regional vascular society. All data were reviewed and subject to a variety of statistical analyses in a blinded retrospective fashion. Factors including sex, increased age (> 70 years), cigarette smoking, chronic pulmonary disease and diabetes did not contribute independently to either increased operative neurologic morbidity or mortality rates. Cardiac disease (P < 0.0001) and chronic renal failure (P < 0.001) correlated independently with increased operative mortality, while hypertension (P < 0.05), cardiac disease (P < 0.01), renal failure (P < 0.0001), emergency surgery (P < 0.0001) and advanced neurologic symptoms at the time of operation (P < 0.0001) were associated with an increased operative stroke rate. In a group of 9021 patients who underwent 9795 carotid endarterectomies with a combined 3.1% incidence of operative neurologic morbidity or mortality (neurologic morbidity, 2.0%; mortality, 1.5%), specific preoperative medical risk factors could be identified. Only cardiac disease and chronic renal failure were associated with both significantly increased operative neurologic morbidity and operative mortality rates.

Do operative results justify tibial artery reconstruction in the presence of pedal sepsis?

An aggressive surgical approach is warranted in all patients with a salvageable weight-bearing pedal surface. Although patients with pedal sepsis (69 limbs) had a lower 30 day limb salvage rate and higher morbidity and mortality rates than those without sepsis (34 limbs), the long-term salvage rates of both groups by life table analysis were not statistically different and remained at the 70 percent level 3 years postoperatively. Peribypass amputation, debridement of the septic foot, or both should be carried out when deemed necessary to decrease the risk of septic complications after revascularization. Other risk factors such as diabetes or heart disease had no bearing on the short-term results of bypass in either the septic or nonseptic group. Autogenous saphenous vein is preferable to synthetic bypass material, especially in patients with ongoing infection. Lastly, even though the medical climate in 1988 must reflect the stark reality of economic restrictions imposed by third-party payors, optimal patient care remains our primary responsibility. We believe that long-term pedal salvage, as achieved by arterial reconstruction, aggressive wound management, and rehabilitation, attains this goal.

Carotid endarterectomy in a metropolitan community: the early results after 8535 operations.

Several retrospective community surveys have provoked speculation concerning the safety of carotid endarterectomy (CEA) throughout the United States. To address this serious issue, surgical outcome was calculated for 8535 CEAs entered prospectively into a computer registry by 51 trained vascular surgeons in a large metropolitan area from 1973 to 1985. A total of 7480 procedures (88%) were performed for symptomatic lesions and 1055 (12%) were performed for asymptomatic stenosis or ulceration. There were 178 operative strokes (2.1%) and 135 early deaths (1.6%), for a combined morbidity-mortality rate of 3.2%. Fatal events were attributed to cardiac disease in 0.7%, neurologic complications in 0.6%, and other causes in 0.3%. The stroke rate (n = 148; 2.0%) in symptomatic patients was better than that in asymptomatic patients (n = 30; 2.8%) (chi 2 = 5.2; p less than 0.025), but the combined morbidity-mortality rates (2.9% and 3.7%) were not statistically different. The incidence of stroke reported by surgeons who performed more than 5 CEAs annually (1.7%) was statistically superior to the stroke rate (3.4%) among those with less experience (chi 2 = 37.1; p less than 0.0001). Nevertheless, both groups had acceptable results that were consistent with their training and continued interest in vascular surgery.

Carcinoma of the colon and rectum in patients less than 40 years of age.

Thirty-one patients less than 40 years of age with carcinoma of the colon were treated at this hospital during the ten years between 1968 and 1978. This accounted for 3.6 per cent of the total number of patients with carcinoma of the colon and rectum seen during this period. Pain, rectal bleeding, change in intestinal habits and weight loss were the most common presenting symptoms. The average delay between the onset of symptoms and treatment was 6.4 months. Mucin-producing and poorly differentiated adenocarcinomas were present in 49 per cent of the patients in this study. Metastases to the ovaries occurred in 23 per cent of the female patients. The five year survival rate was only 22 per cent. The importance of early diagnosis and treatment and, in the female patient, of oophorectomy is emphasized.

Choledocholithiasis associated with acute cholecystitis.

A retrospective review of the records of 1,507 patients with a diagnosis of cholecystitis was conducted for the five-year period, 1972 to 1977. Of this group of patients, a histopathologic diagnosis of acute cholecystitis was established in 154 patients (10.2%). Common duct calculi were detected in 17 of these 154 patients, an incidence of 11%. Preoperative evaluation by means of serum bilirubin and alkaline phosphatase levels and intravenous cholangiography was unsatisfactory for consistent demonstration of choledocholithiasis in the presence of acute cholecystitis. Intraoperative cholangiography was found to be the most reliable method for detection of common duct calculi and was successfully employed in 14 of 17 patients with choledocholithiasis. The remaining three patients had palpable stones.

Hemangiopericytoma. Literature review and clinical presentations.

Hemangiopericytomas are soft tissue sarcomas of vascular origin, comprised of pericytes. They have been reported in the extremities, head and neck, back, retroperitoneum, and abdomen. The criteria for the diagnosis and treatment are reviewed. Wide local ablation of the tumor is necessary to prevent local recurrence. Fifty per cent are malignant, although regional node spread is infrequent. Ultrastructural studies are necessary to differentiate hemangiopericytomas from other sarcomas. Long-term follow-up of all cases is essential for optimal clinical management.