Clinical significance of free-floating venous thrombi.

To evaluate the fate of free-floating venous thrombi, venous duplex scans of 5238 consecutive lower extremities over a 2 1/2 year period were reviewed. Acute deep venous thrombosis was found in 732 cases. Eighty-two free-floating deep venous thrombi were diagnosed in 73 of these patients. Nine of 72 patients (13%) had pulmonary emboli as diagnosed by ventilation perfusion scanning or pulmonary angiography or both. Seven of these patients (78%) had a pulmonary embolus before the initial duplex scan. Two (22%) had a pulmonary embolus after the diagnosis of free-floating thrombus. Thirty-three of 73 patients (45%) had follow-up of free-floating thrombi by duplex scanning performed in the acute period (less than 30 days): 18 (55%) showed attachment of the free-floating thrombus, three (9%) showed progression in size of the free-floating tail, and eight (24%) showed decrease in size or resolution of the free-floating thrombus. Four (12%) showed persistent thrombus without evidence of resolution, propagation, or attachment. In conclusion, free-floating venous thrombi occurred in 10% of cases of acute deep venous thrombosis. Only 13% of free-floating thrombi were associated with clinically significant pulmonary emboli, confirmed by ventilation perfusion scanning. Usually the embolus occurred before diagnosis of free-floating thrombus. Most free-floating thrombi followed noninvasively by duplex scanning do not embolize, but rather they become attached to the vein wall or resolve.

Venous anomalies encountered in aortoiliac surgery.

Reconstructive procedures of the aortoiliac system are extremely common. Aside from ruptured aneurysms, most severe intraoperative hemorrhage is due to venous injuries. The ability to recognize and manage venous anomalies is essential. This article presents a review of major venous anomalies including (1) transposition of the inferior vena cava, (2) double vena cava, (3) retroaortic left renal vein, (4) circumaortic renal collar, and (5) preaortic iliac venous confluence. Embryologic development, operative recognition, and techniques of operative management are discussed. A case report is presented in which an anomaly similar to a preaortic iliac confluence was discovered during aortic reconstruction for a ruptured abdominal aortic aneurysm. This case differs from previously reported cases of preaortic iliac confluence in that the right common iliac vein persisted in its course anterior to the right common iliac artery.

Ecthyma gangrenosum in a burned child.

The history of ecthyma gangrenosum has been presented, as well as its pathological diagnosis, prognosis and natural history. The history of forms of treatment has been outlined and the grave prognosis is emphasized. A case presentation introduces the experience at the Cincinnati Shriners Burns Institute. From a review of the literature and the experience at the Shriners Burns Institute, a suggestion for optimal treatment has been proposed. The particulars of this treatment include: early recognition, general nutritional and metabolic support, as well as high-dose aminoglycoside and semi-synthetic penicillin therapy, administered parentally and by sub-eschar clysis. Despite the grave prognosis, attention to these factors should result in optimal survival of patients with ecthyma gangrenosum.