Arterial spasm mimicking superficial femoral artery trauma. Case report.

The existence of traumatic arterial spasm in large arteries is questionable in current literature. We report a case of a 19-year old man with comminuted unstable femur fracture who presented with an ischemic foot. Localized arterial spasm was revealed in the middle portion of the superficial femoral artery triggered by the external pressure of a spicular bone segment was revealed by arteriography. Complete resolution of ischemic symptoms followed fracture reduction. Traumatic arterial spasm although rare does exist.

Transposed brachial-basilic arteriovenous fistulas versus prosthetic upper limb grafts: a meta-analysis.

BACKGROUND: Controversy exists regarding the best type of arteriovenous (AV) fistula to be formed in secondary and tertiary access procedures when primary fistulas have failed. This meta-analysis aimed to compare transposed brachial-basilic AV fistulas (BBAVFs) with upper limb AV prosthetic grafts. METHODS: A literature search of the MEDLINE and SCOPUS databases was performed to identify comparative studies reporting outcomes for both BBAVFs with upper limb AV prosthetic grafts. Meta-analysis techniques were applied to identify differences in outcomes between the two groups regarding primary and secondary 1-year failure rates. RESULTS: Eleven relevant studies, involving 1509 patients, met the inclusion criteria and were incorporated in the final analysis; however, only one was randomised controlled trial. The pooled odds' ratio (OR) estimate for the primary and secondary failure rates at 1 year was 0.67 (CI 0.41-1.09) and 0.88 (CI 0.69-1.12), respectively, showing no difference in the outcome between the two groups. The re-intervention rate was higher for prosthetic grafts (0.54 per BBAVF versus 1.32 per graft). In a small subgroup of two studies comparing BBAVFs with forearm grafts the pooled estimate for 1-year primary failure rate was in favour of the BBAVF group (OR 0.3, CI 0.15-0.58, p=0.0004) suggesting that forearm grafts were inferior having a 3-fold risk of failure at 1 year. CONCLUSION: This analysis supports the use of BBAVF early in difficult access cases prior to the use of prosthetic grafts. However, the latter conclusion is debatable due to heterogeneity, small size and non-randomised design of the included studies.

Peroneal artery pseudo-aneurysm following blunt injury.

The peroneal artery is injured less frequently than the popliteal and tibial arteries, because of its anatomical relationships. Pseudo-aneurysm of the peroneal artery due to a blunt injury is a rare complication. These injuries are usually occult, but more have been identified with the introduction and increasing use of angiography, following a high clinical suspicion of the trauma team involved. We report a case of peroneal artery false aneurysm following blunt trauma, presented with intermittent haemorrhage. In trauma, isolated peroneal artery pseudo-aneurysms, although rare, may occur. Early diagnosis can be confirmed by angiography and when less-invasive procedures cannot be applied, a posterior approach is an attractive surgical option in the management of proximal peroneal artery traumatic lesions.

The significance of medial sural artery integrity in popliteal artery trauma: a case report.

Two patients with popliteal artery trauma who underwent secondary amputations due to refractory calf sepsis despite a patent arterial repair are presented in this case report. The medial sural artery, the main arterial supply of the medial head of the gastrocnemius, was surgically severed in both patients owing to the use of a continuous medial incision from the supra level to infragenicular level. The compromised arterial supply of the medial head of the gastrocnemius muscle may have contributed to the devitalization of the muscle and the subsequent calf sepsis, and it is speculated that this was related to the unfavorable outcome.

Femoral-anterior tibial reconstructions using cuffed PTFE grafts: routing alternatives.

BACKGROUND: The anterior tibial is the less often used artery for distal anastomosis in infrapopliteal bypass with synthetic grafts; however, several investigators argue against even an attempt to use non-autologous material for such distal reconstructions. Only few studies report patency rates mixing-up popliteal below-knee and various crural bypasses. PATIENTS AND METHODS: Nineteen consecutive femoral-anterior tibial cuffed PTFE bypass grafts, either via the lateral (n = 15) or interosseous (n = 4) route, were inserted in a 10-years period. RESULTS: The 1-year and 2-year primary patency rate was 71% and 53%, respectively. It is noteworthy that in one patient a graft positioned via the lateral route remained patient for ten years. No complications were observed regarding the routing methods, whatever increased operating time was required in the interosseous route cases. The 3-year cumulative survival rate for this particular group of patients was 32%. CONCLUSIONS: Our data indicate that femoral-anterior tibial bypasses using cuffed PTFE grafts via the lateral route result in an acceptable medium-term patency. As such patients have a limited life expectancy, these procedures should be performed when an autologous vein is not available, as opposed to primary amputation.

Influence of surgeons' specialty on the selection of vascular access for hemodialysis treatment.

BACKGROUND/AIMS: Various patient-related factors could not explain the variability of access types across facilities in the published literature. The aim of this study was to investigate the influence of surgeons' specialty on access type selection for hemodialysis treatment. METHODS: The directors (nephrologists) of all renal units in Greece (n = 92) were surveyed by a closed questionnaire. RESULTS: The response rate was 75%. There was no statistically significant difference in the percentage of patients predominantly with autologous arteriovenous fistulae between units where only vascular surgeons were performing access surgery and those where either general surgeons or transplant surgeons were operating (mean value in all renal units 80.8%, range 43-97%). However, the difference between the three groups of renal units regarding their surgeons' ability to create complex access procedures and to correct complications (as an index of surgeons' skill) was statistically significant (p < 0.001). CONCLUSION: The general surgeons of the new generation are not often using vascular surgical techniques and may have less opportunities to develop expertise in vascular access creation.

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.