Glomangioma of the upper limb associated with hypoplastic-dysplastic superficial venous system.

The diagnosis and therapy of vascular malformations is difficult. An important factor, which influences the therapeutic approach, is the complicated vascular network of the lesions. The frequent involvement of various structures (muscles, bones or other organs) makes the surgical intervention arduous. Glomus tumors are rare, symptomatic (painful) lesions, with dimensions ranging 3-10 mm and usually subungual location, which need radical resection as a therapy. The case we present is the first one where a glomus tumor presents as a hypoplastic-dysplastic superficial venous system, located parallel to the normal superficial venous system of the left upper extremity, resembling a form of varicosities. The atypical clinical presentation and the unique morphology classify this case in a very limited category of nosological entities.

Spontaneous healing of chylous ascites after abdominal aortic aneurysm repair.

Postoperative chylous ascites is a rare complication of aortic surgery. This report presents a patient with chylous ascites after abdominal aneurysmectomy. After a retrospective analysis of full blood count measurements, we observed an association between the number of lymphocytes in the patient's total blood count and the development and evaluation of chylous ascites. We believe that this hypothesis might be helpful, as it suggests that the number of lymphocytes in a patient's total blood count may be used as a prognostic factor for the development of chylous ascites. Furthermore, our patient appears to be of interest from a therapeutical point of view, since repeated therapeutic paracenteses alone were sufficient in treating chylous ascites, a finding in contradiction to international literature.

Patency of autologous and prosthetic arteriovenous fistulas in elderly patients.

OBJECTIVE: To compare the patency of autologous and graft-bridging (prosthetic) arteriovenous (AV) fistulas in patients 70 years of age or more. DESIGN: Non-randomised comparative study. SETTING: University hospital, Greece. PATIENTS: 114 patients aged 70 years or more (mean 78) who required 135 consecutive angioaccess procedures during the 8-year period January 1990-December 1997. INTERVENTIONS: 68 autologous and 67 prosthetic procedures, 64 of the prosthetic procedures being proximal brachioaxillary AV arm grafts. MAIN OUTCOME MEASURES: Primary and secondary cumulative patency rates and cumulative survival. RESULTS: Life table analysis showed that the 3-year secondary patency (medium term patency) was significantly superior in the prosthetic group (58% compared with 44%, p = 0.04). Cumulative survival at 3-years was 21%. CONCLUSIONS: A proximal brachioaxillary prosthetic AV graft is a good alternative as initial primary access in elderly patients who are not suitable for an autologous proximal AV fistula. At this age long term patency and conservation of proximal access sites are of minimum importance because of their limited life expectancy.

Indications for surgical treatment of angioaccess-induced arterial "steal".

BACKGROUND: Arterial "steal" is a well-known complication following proximal arteriovenous (AV) fistula, but its manifestations comprise a wide spectrum of symptoms and there are no clear indications for those patients who need surgical repair. STUDY DESIGN: Among 180 consecutive AV fistulas of various configurations, with the brachial artery as the donor artery in all patients, 111 patients were studied retrospectively (group A) and 69 patients were studied prospectively (group B). Patient records were reviewed in group A, and the decision for surgical correction of limb-threatening steal was based on clinical grounds only. In group B, all patients were followed prospectively; postoperative systolic blood pressure measurements were obtained, and a systolic pressure index (SPI) was calculated (postoperative forearm systolic pressure divided by contralateral forearm systolic pressure). In patients with an SPI < 0.6, nerve conduction studies (NCS) were performed. The decision for operation in this group was based on clinical examination, SPI, and NCS. RESULTS: Seven patients were operated on for steal-induced limb-threatening ischemia; in all seven patients, ischemia developed immediately after access construction. One additional patient with mild symptoms and deterioration in repeated NCS was considered a candidate for ischemic monomelic neuropathy and was successfully operated on 1 month later. The ligation-bypass technique was used in all patients, consisting of arterial ligature distal to the takeoff of the graft and short arterial bypass from a point proximal to the inflow of the access to a point just distal to ligation. In 94% of the patients, some degree of distal ischemia was detected (SPI < 0.8); patients with SPI < 0.5 were most likely to have impaired NCS. CONCLUSIONS: Steal-induced limb-threatening ischemia necessitating immediate surgical repair occurred in 3.9% (7 of 180) of our patients. The decision for surgical correction of steal should be based on clinical examination. Nerve conduction studies may be useful in patients who have an SPI value < 0.5 to detect candidates who might develop ischemic monomelic neuropathy. In similar patients, surgical treatment of steal should be offered.

POSSUM and APACHE II scores do not predict the outcome of ruptured infrarenal aortic aneurysms.

Forty consecutive patients were admitted alive to the operating theater with ruptured infrarenal aoritc aneurysms in a 3-year period and were assessed preoperatively with two scoring systems: the POSSUM (physiological and operative severity score for the enumeration of mortality) and the APACHE II (acute physiologic and chronic health evaluation). The aim of the study was to investigate the capacity of the two scores to predict the patients' outcome. The operative mortality of the series was 55% (22/40). The average POSSUM score was 63.3 for survivors and 66.5 for the nonsurvivors (difference not statistically significant). APACHE II score averaged 11.3 in survivors and 14.5 in nonsurvivors (p = 0.02). APACHE II score 17 was the threshold value with the highest combined specificity and sensitivity; however, at this point the positive predictive value for a death was 92% and the negative predictive value was 63%. Interestingly, the only single factor in univariate analysis affecting mortality was the preoperative platelet count and is not taken into account in neither of the two scoring systems. POSSUM failed in predicting the outcome of ruptured infrarenal aortic aneurysms. APACHE II was a good predictor of outcome; however, its power to predict the outcome in any given individual patient was limited. As precise prediction is impossible, repair in every patient should not be denied.