Acute renal impairment due to a primary aortocaval fistula is normalised after a successful operation.

OBJECTIVES: To study renal function in patients with aortocaval fistula, before and after surgery. DESIGN: Retrospective study. MATERIAL AND METHODS: During the last 22 years nine male patients (median age 67, age range 50-72) with spontaneous aortocaval fistula in combination with AAA were operated upon. This constitutes 4% of the patients with ruptured AAA and 1.5% of all patients with AAA. RESULTS: A preoperative diagnosis of aortocaval fistula was established in three of the nine cases. The medium duration of symptoms prior to surgery was 5 days (range 4 h-14 days). The fistula was combined with an extravasating ruptured AAA in only three patients. Seven of the patients had acute renal insufficiency, with creatinine levels of in median 292 mumol (IQR 218-342). Creatinine declined to 172 mumol/l (IQR 170-313) on the fifth postoperative day in uncomplicated cases and to 86 mumol at discharge. One patient died due to multi-organ failure, whereas the other left hospital well and alive with normal renal function. CONCLUSION: Acute preoperative renal insufficiency due to an aortocaval fistula in patients with AAA is often due to venous congestion, and is normalised after successful surgery.

What is new in the prophylaxis and treatment of venous thromboembolism?

Deep venous thrombosis continues to be a frequent complication of surgery and trauma. The topic is controversial with regard to diagnosis, indication for prophylaxis, and suitable methods for prophylaxis and therapy. We review some of the highlights of the extensive literature in this field during the last few years. Particular emphasis is given to new trends in diagnostic methods, newly discovered genetic factors for thrombophilia, and the use of heparins for prophylaxis and therapy of thromboembolic disease.

Pharmacological prophylaxis against postoperative graft occlusion after peripheral vascular surgery: a world-wide survey.

OBJECTIVES: To define current practice regarding the use of pharmacological prophylaxis to prevent postoperative graft occlusion. DESIGN: Prospective open questionnaire. MATERIALS AND METHODS: Questionnaires regarding this subject were sent to vascular surgeons throughout the world to analyse current practice. RESULTS: 651 questionnaires were returned with a response rate of 62% and form the basis for this report. Data from 100,334 vascular reconstructions were reported in this survey. Prophylaxis against postoperative graft occlusions was common. Treatment periods were usually greater than 1 year. Among carotid surgery patients, 82% received prophylaxis, consisting mainly of low-dose acetysalicylic acid (ASA). In Mid-Europe the use of oral anticoagulation was more common than in other regions (p < 0.001). Among aneurysm surgery patients, 38% received prophylaxis. For infrainguinal bypass, ASA in low dose was the most commonly used agent worldwide. However, oral anticoagulation was more frequent in Mid-Europe, in contrast to South America where the combination of ASA and dipyridamole was most common. Considerable geographical differences regarding patient selection, the frequency of specific procedures and operative techniques existed. CONCLUSIONS: Important world-wide differences exist regarding prophylaxis for postoperative graft occlusion.

Heparin and protamine use in peripheral vascular surgery: a comparison between surgeons of the Society for Vascular Surgery and the European Society for Vascular Surgery.

It was the intent of this study to document, in general, the patterns and complications of heparin and protamine usage during carotid endarterectomy, aortic and femoral-popliteal-tibial reconstructions for occlusive disease, elective and emergent abdominal aortic aneurysmectomy, thromboembolectomy, and dialysis arteriovenous (AV) fistula placement by surgeons from North America and Europe. All vascular surgeons from the Society for Vascular Surgery (SVS) and the European Society for Vascular Surgery (ESVS) were surveyed by a voluntary, self-reported questionnaire. Six hundred and forty-six completed questionnaires (284 from SVS and 362 from ESVS), representing a 62% response rate, were returned for evaluation. Systemic and regional administration of heparin was common during vascular procedures performed by both SVS and ESVS surgeons. Use of protamine to reverse heparin anticoagulation varied among SVS and ESVS surgeons, respectively, during: carotid endarterectomy (54% vs. 26%, p < 0.01), elective aortic reconstruction for occlusive disease (58% vs. 23%, p < 0.001), elective aortic reconstruction for abdominal aortic aneurysm (63% vs. 27%, p < 0.001), and femoral-popliteal-tibial reconstruction (44% vs. 15%, p < 0.001). Adverse reactions to protamine among the 25,219 and 12,902 cases reported from SVS and ESVS surgeons, respectively, included: hypotension (1209 and 495 cases), pulmonary artery hypertension (65 and eight cases), anaphylaxis (52 and 10 cases), and death (seven and two cases). These adverse responses accounted for 5.3% and 4.0% of the SVS and ESVS cases, respectively. Although this study is subject to the known limitations of a retrospective survey, it is clear that heparin use is common. Protamine reversal of heparin anticoagulation is more common in North America.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term results of arterial reconstruction of the upper extremity.

Arterial reconstructive surgery for upper limb ischaemia of non-traumatic non-embolic origin is uncommon in comparison to that of the lower extremities and long-term follow-ups are rare. Forty-eight patients (27 females, 21 males) with a median age of 58 years (range 22-88) were retrospectively analysed for risk factors, survival and patency rates. Seventy-three per cent were smokers, 42% had hypertension and 33% had had previous vascular interventions. Diabetes was only seen in 4% of the cases. Effort fatigue was the dominant cause for surgery followed by micro-embolism and rest pain or gangrene. The left side was more frequently affected with 30 procedures compared to 18 on the right. Bypass with either Dacron, ePTFE or autologous vein was the most frequent procedure in 56% of the cases followed by thrombendarterectomy (23%) and subclavio-carotid transposition (11%). Arm-arm index rose from 0.63 (SD 0.28) preoperatively to 1.02 (SD 0.12) after 1 month and at the end of follow-up (median 75 months) it was 0.96 (SD 0.15). Cumulative survival rates were at 1 month 98%, 1 year 91%, 5 years 81% and at 10 years 73%. Cumulative primary patency rates at the same intervals were 96, 96, 88 and 80%, respectively. Thus the survival rate and patency rate are favourable in comparison with arterial surgical procedures of the lower extremity.

Percutaneous transluminal renal angioplasty versus surgical reconstruction of atherosclerotic renal artery stenosis: a prospective randomized study.

PURPOSE: The purpose of this prospective randomized study was to compare percutaneous transluminal renal angioplasty (PTRA) and operation as initial therapy with regard to technical results, primary and secondary patency, and effects on blood pressure and renal function in patients with atherosclerotic unilateral renal artery stenosis. METHODS: Fifty-eight patients who did not have diabetes, who were less than 70 years of age, and who had severe hypertension and significant stenosis were randomized to receive PTRA or operation. Angiography was performed 10 days, 1 year, and 2 years after treatment to verify patency, and blood pressure and renal function were simultaneously evaluated. RESULTS: Technically, PTRA was successful in 83% and operation in 97% of patients. The primary patency rate after 24 months was 75% in the PTRA group and 96% in the operative group in technically successful cases. The secondary patency rate in the PTRA group was 90% and in the surgical group 97%. To achieve these results four patients in the PTRA group required operation, and one patient in the surgical group required PTRA. Hypertension was cured or improved after additional treatment in 90% of the patients after PTRA and 86% after operation. The corresponding figures for improved or unchanged renal function were 83% and 72%, respectively. After additional treatment, effects on blood pressure and renal function did not differ. Seventeen percent of the patients treated with PTRA required surgical intervention. CONCLUSIONS: PTRA is recommended as first choice of therapy for atherosclerotic renal artery stenosis causing renovascular hypertension if combined with intensive follow-up and aggressive reintervention.