RESUMO
Conditions that necessitate surgery frequently arise in patients with chronic liver disease and cirrhosis. Because cirrhosis has the ability to cause physiologic derangements in every organ system in the body, clinicians face significant challenges in preoperative preparation of the patient with cirrhosis in order to decrease postoperative morbidity and mortality. Emergent operations add an extra dimension of complexity to the clinical picture, due to limited preoperative time to prepare the patient with cirrhosis for surgery. In cases of severely decompensated cirrhosis, clinicians should have in their armamentarium possible alternatives to surgery that can be used to temporize the emergent nature of the disease and improve patient outcomes. The classification of cirrhotic liver disease by Child and Turcotte was initially utilized to predict mortality in patients undergoing surgically placed shunts for portal hypertensive bleeding. Subsequent studies have pointed to the fact that other general and thoracic surgery procedures can be assigned predicted mortality rates according to a similar classification scheme, the modified Child-Pugh score. Patients with cirrhosis facing surgery should undergo a careful history and physical examination and should be accurately placed into a designated Child-Pugh category. Because the modified Child-Pugh class is the most reliable determinant of postoperative morbidity and mortality, every attempt should be made to upgrade a patient's class in a favorable direction prior to surgery. Patients should be carefully evaluated for the presence of ascites and dietary alterations. In addition, medical management with diuretics should be employed to prevent postoperative ascites leak and possible infectious complications including bacterial peritonitis. Perhaps one of the most feared complications in the patient with cirrhosis facing surgery is hemorrhage. Because the liver is vital in maintenance of coagulation homeostasis, several pharmacologic adjuncts may be administered to correct any coagulopathy in the peri-operative period. Several diseases such as cholelithiasis and peptic ulcer disease are known to be more prevalent in the cirrhotic patient, and clinicians treating these diseases should have a thorough understanding of the pathophysiology of cirrhosis and portal hypertension. Patients with cirrhosis and portal hypertensive bleeding that are considered good surgical candidates (ie, Child-Pugh class A) may benefit from surgical portasystemic shunt in contrast to angiographically placed portacaval shunt (ie, transjugular intrahepatic portosystemic shunt ) due to the lack of durable patency and cost effectiveness in the latter. In patients with cirrhosis awaiting orthotopic liver transplantation, TIPS may be a lifesaving temporizing technique that is utilized as a bridge to transplantation.
RESUMO
BACKGROUND: Infected femoral artery pseudoaneurysms (IFAPs) secondary to percutaneous arterial access, injection of illegal substances, and from infected synthetic grafts, appear to be increasing in incidence. Ligation of IFAPs without revascularization offers control of infection but may risk limb ischemia. Revascularization with extraanatomic synthetic grafts may risk reinfection and abrupt thrombosis. Excision of IFAPs with revascularization using superficial femoral popliteal vein (SFPV) provides both control of infection and excellent limb perfusion. STUDY DESIGN: A retrospective review was conducted of patients diagnosed with IFAP who underwent resection and revascularization with SFPV at a single medical center. Outcomes measured included reinfection and amputation rate. These were compared with other series using various methods to treat IFAPs. RESULTS: Eleven patients with IFAP were encountered from 1992 to 2004. Mean age was 64 years (+/-10 SD). Five patients developed IFAP secondary to percutaneous arterial access procedures. Four patients developed infected femoral artery pseudoaneurysms secondary to synthetic graft infection. Two patients developed IFAP secondary to injection of illegal substances in the femoral region. All patients had positive wound cultures initially. Staphylococcus was the most common organism found in wound cultures. All patients underwent resection of IFAP with lower extremity revascularization using SFPV. There was no incidence of limb ischemia and no perioperative deaths in this series. CONCLUSIONS: Excision of IFAP with revascularization can be successfully achieved using SFPV. This method may prove to be superior to other methods with apparent higher patency rates and resistance to reinfection.
