"General surgical pearls" for the anterior exposure of vertebral fractures.

Recently interest has been increasing in the anterior surgical approach for spinal cord decompression and bony stabilization of vertebral compression fractures. Our neurosurgical spine service routinely consults us to provide anterior operative exposure and wound closure for all levels of the thoracic and lumbar vertebral spine. Averaging about 30 exposures per year we have developed an excellent operative experience with these vertebral exposures. With no complete general surgery reference on anterior vertebral identified this summary of our "general surgical pearls" that we have learned and/or have developed should significantly aid other general and trauma surgeons who may be asked by their neurosurgical and/or orthopedic surgical colleagues for assistance with these operations.

Abdominal aortic aneurysm repair.

Newer, minimally invasive catheter-based endovascular technology utilizing stent grafts are currently being evaluated for abdominal aortic aneurysm (AAA) repair. A retrospective review of all (3 years) consecutive, non-ruptured elective AAA repairs was undertaken to document the results of AAA surgical repair in a modern cohort of patients to allow a contemporary comparison with the evolving endoluminal data. One hundred twenty-one AAAs were identified in a male veteran population. Mean age was 68.5 +/-7.7 years. Medical history review showed hypertension in 55%, heart disease in 73.5%, peripheral vascular disease in 21%, stroke and transient ischemic attacks in 22%, diabetes mellitus in 7%, renal insufficiency in 10%, and smoking history in 80%. The AAA size was documented with ultrasound (5.2 +/-1.3 cm, n=40) and computed tomography (5.6 +/-1.3 cm, n=100). Fifty-nine percent had angiography. Intraoperative end points included an operative time of 165 +/-6.3 minutes from incision to dressing placement. A Dacron tube graft was used in 78%, the remaining were Dacron bifurcated grafts. A suprarenal clamp was used in 8% for proximal aortic control with juxtarenal aneurysms. A pulmonary-artery catheter was placed in 69%. A transverse incision was used in 69% of patients and a midline incision was used in the rest. Estimated blood loss was 1505 +/-103 mL; cell saver blood returned 754 +/-53 mL; crystalloid/Hespan 4771 +/-176 mL; banked packed red blood cells 0.75 +/-0.11 U. Time to extubation was, in the operating room (78.5%), on the day of the operation (5.0%), postoperative day (POD) 1 (12.4%), POD2 (1.7%), POD3 (0.8%), and one case was performed with epidural anesthesia only. Postoperative end points included a 30-day mortality rate of 1.6% (two patients). Postoperative morbidity included wound dehiscence 0.8%; sepsis, urinary tract infection, wound infection, leg ischemia, ischemic colitis, and stroke each had an incidence of 1.6%; myocardial infarction, congestive heart failure, pneumonia, re-operation for suspected bleeding, and ileus or bowel obstruction occurred with an incidence of 3.3%. No significant increase in serum creatinine levels was noted. Time to enteral fluids/nutrition was 3.5 +/-0.08 days. Patients were out of bed to a chair or walking by 1.3 +/-0.06 days postoperatively. The length of stay in the intensive care unit (ICU) was 2.0 +/-0.12 days and postoperative hospital stay was 6.6 +/- 0.33 days. Transfusion requirement for the hospital stay was 1.6 +/-0.2 U per patient. This review highlights a cohort of male veteran patients with significant cardiac co-morbidity who have undergone repair with a conventional open technique and low mortality and morbidity rates. This group had rapid extubation, time to oral intake, and ambulation. In addition, ICU and hospital stays were relatively short.

Folate supplementation inhibits intimal hyperplasia induced by a high-homocysteine diet in a rat carotid endarterectomy model.

OBJECTIVE: Hyperhomocysteinemia has been implicated as a causative factor in intimal hyperplasia development. The addition of dietary folate in a hyperhomocysteinemia, carotid endarterectomy rat model is postulated to decrease plasma homocysteine levels and, in turn, reduce post-carotid endarterectomy intimal hyperplasia. METHODS: Each rat was fed one of six diets: (1) lab chow with no folate (n = 7), (2) lab chow with 10 mg/kg folate added (n = 3), (3) lab chow with 25 mg/kg folate added (n = 3), (4) a homocysteine diet with no folate (n = 7), (5) a homocysteine diet with 10 mg/kg folate added (n = 5), or (6) homocysteine diet with 25 mg/kg folate added (n = 5). Each rat then underwent an open carotid endarterectomy. In 2 weeks, intimal hyperplasia in the carotid artery was measured. Plasma homocysteine and folate levels were measured. RESULTS: Plasma folate levels rose with folate administration. Plasma homocysteine in the lab chow group was 5.4 +/- 0.5 micromol/L and did not change with the addition of folate. In the homocysteine diet group, plasma homocysteine rose 10-fold over the lab chow group (51.9 +/- 6.5 vs 5.4 +/- 0.5, micromol/L, P <.0001). In the group fed a homocysteine diet with 10 mg/kg folate added, a significant decrease in plasma homocysteine was observed (17.5 +/- 8.5 vs 51.9 +/- 6.5, micromol/L, P =.0003). In the group fed a homocysteine diet with 25 mg/kg folate added, plasma homocysteine levels were further reduced to levels seen in the lab chow group (12.6 +/- 2.6 vs 5.4 +/- 0.5, micromol/L, P = not significant). The relationship between plasma folate and homocysteine was inverse (R = 0.39, P =.0036). Luminal stenosis due to intimal hyperplasia was minimal in lab chow groups and unaffected by folate. The homocysteine diet group demonstrated post-carotid endarterectomy luminal stenosis due to intimal hyperplasia (60.9% +/- 9.2%). In the group fed a homocysteine diet with 10 mg/kg folate added, intimal hyperplasia was reduced, compared with the homocysteine diet group (32.6% +/- 7.4% vs 60.9% +/- 9.2%, P =.009). In the group fed a homocysteine diet with 25 mg/kg folate added, intimal hyperplasia was reduced to lab chow group levels (10.8% +/- 0.8% vs 4.8% +/- 1.0%, P = not significant) and was reduced, compared with the group fed a homocysteine diet with 10 mg/kg folate added. CONCLUSION: The use of folate in this hyperhomocysteinemia carotid endarterectomy model and the resultant attenuation of plasma homocysteine elevation and intimal hyperplasia development lend strong support to homocysteine being an independent etiologic factor in post-carotid endarterectomy intimal hyperplasia.

Infectious complications resulting from use of hemostatic puncture closure devices.

BACKGROUND: Femoral access site complications have increased as the fields of invasive cardiology, radiology, and endovascular surgery have emerged. In order to address one of these complications, hemorrhage, the hemostatic puncture closure devices were developed. METHODS: Retrospective review of cardiac catheterizations performed at a single institution to investigate infectious groin complications related to use of the Perclose Prostar and Techstar devices. RESULTS: Infectious groin complications were significantly higher in the Perclose group as compared with manual compression. Three patients had clinical and laboratory evidence of arterial infection whereas 2 had soft tissue infections. All 5 required operative intervention ranging from incision and drainage to arterial reconstruction. Hemorrhagic complications were not significantly different between the two groups. CONCLUSIONS: The Perclose devices provide hemostasis after femoral artery catheterization similar to manual compression. However, infectious groin complications appear to be more common with these devices.

Critical leg ischemia resulting from interruption of collaterals by harvest of the rectus abdominis free flap: endovascular salvage.

In the setting of aortoiliac occlusive disease, the inferior epigastric artery may be an important pathway for collateral blood supply to the lower extremities. A 72-year-old man developed critical ischemia of both legs after harvest of a rectus abdominis free flap as a result of interruption of the inferior epigastric artery. In patients with aortoiliac occlusive disease, the contribution of the inferior epigastric artery to lower extremity blood flow should be evaluated noninvasively. In the setting of reversed flow, the inferior epigastric artery usually should not be divided.

Blue toe syndrome: treatment with intra-arterial stents and review of therapies.

PURPOSE: To determine if intra-arterial stent placement can adequately treat lesions producing microemboli to the lower extremities. MATERIALS AND METHODS: During a 6.5-year period, 15 patients presenting with blue toe syndrome had 16 presumed embolic lesions treated with intra-arterial stents. These patients were evaluated during routine clinical follow-up during a 6-month period. This evaluation included physical and noninvasive arterial examinations. When patients could not return for follow-up, hospital, clinical, vascular laboratory, and radiology records were reviewed to assemble the appropriate information. Outcomes included symptoms of recurrent emboli, amputation, and death. RESULTS: Treated embolic lesions included two aortic stenoses, three bilateral iliac artery stenoses, nine unilateral iliac artery stenoses (one patient received separate treatment of unilateral iliac lesions), and two superficial femoral artery stenoses. Patients were followed-up for a mean of 18 months. Eight of 15 patients (53%) were improved or stable without complications. There were eight negative outcomes experienced in seven patients. Three patients (20%) were deceased at follow-up. Four patients (27%) had undergone amputation; one transmetatarsal amputation and three below-the-knee amputations. Only one of these was related to progressive disease in the treated extremity (7%). One patient (7%) experienced recurrent embolic symptoms. Stents were patent in all patients. CONCLUSION: Patients with blue toe syndrome are at high risk of limb loss and mortality despite treatment. Intra-arterial stent placement provides an alternative to standard surgical treatment. Further studies are needed to define the optimum therapy.

Surgical complications from hemostatic puncture closure devices.

BACKGROUND: For securing immediate hemostasis following percutaneous arterial catheterization, the Food and Drug Administration has approved three hemostatic puncture closure devices. We reviewed our institutional experience with one device (Angio-Seal). METHODS: A retrospective, single-center, nonrandomized observational study was made of all vascular complications following femoral cardiac catheterization. RESULTS: An immediate mechanical failure of the device was experienced in 34 (8%) patients. Surgical repair was required in 1.6% (7 of 425) of patients following Angio-Seal versus 0.3% (5 of 1662) following routine manual compression (P = 0.004). In 5 patients, the device caused either complete occlusion or stenosis of the femoral artery. The polymer anchor embolized in 1 patient and was retrieved with a balloon catheter at surgery. CONCLUSION: During the first year of utilization of a percutaneous hemostatic closure device following cardiac catheterization, we observed a marked increase in arterial occlusive complications requiring surgical repair. Surgeons must be familiar with the design of these devices to achieve precise repair of surgical complications.

Hyperhomocysteinemia increases intimal hyperplasia in a rat carotid endarterectomy model.

PURPOSE: This preliminary study investigated the ability to elevate the serum homocysteine (H[e]) levels and investigated the increases in postoperative neointimal hyperplasia (IH) in an environment with hyperhomocysteinemia and the resultant restenosis in a rat carotid endarterectomy (CEA) model. METHOD: The 9 rats for the control group were fed rat chow, and the 8 rats for the H(e) group were fed H(e)-supplemented rat chow for 2 weeks before and after CEA. The animals underwent anesthesia, and a left common CEA was performed. After 14 days, the serum H(e) levels were measured and the left carotid artery was harvested and elastin stained. Morphometric measurements were used to calculate the area of stenosis of the lumen. The mean and the standard deviation of the mean were determined. The 2 groups were compared with the Mann-Whitney test and a linear regression model. Three additional rats per group were studied, with carotid artery sectioning with double immunohistochemical staining for 5-bromodeoxyuridine (BrdU) and alpha-smooth muscle (alpha-SM) actin. RESULTS: The serum H(e) level in the H(e) group was 36.32 micromol/L +/- 15.28, and in the control group the level was 5.53 micromol/L +/- 2.06 (P =.0007). IH presented as percent lumen stenosis was 21.89% +/- 4.82% in the H(e) group and 4.82% +/- 1.64% in the control group (P =.0007). The linear regression model of the serum H(e) levels and the percent stenosis showed a linear relationship (r2 =.72). The alpha-SM actin staining revealed that nearly all of the cells in the IH area were of smooth muscle or myofibroblast origin and that 10.1% +/- 2.6% of the cells were stained for BrdU in the control group versus 23% +/- 7.1% in the H(e) group. Also, 9.3% +/- 2.6% of the cells in the IH area were stained for BrdU and for alpha-SM actin versus 19.1% +/- 5. 6% stained for both BrdU and alpha-SM actin in the H(e) group. CONCLUSION: This is the first study to examine IH after CEA and hyperhomocysteinemia in rats. The study shows that the elevation of serum H(e) levels can be obtained by feeding rats modified diets with added H(e). The consistent elevation of serum H(e) levels was associated with more than 4 times the amount of IH after a CEA in a rat model.

The anterior extrapleural approach to the thoracolumbar junction revisited.

General surgeons often provide the exposure for the anterior repair of vertebral body lesions. The standard anterior approach to the thoracolumbar junction (T11-L1) is a transpleural 9th or 10th rib thoracoabdominal incision. From October 1995 through March 1997, 22 patients underwent anterior repair of thoracolumbar junction vertebral lesions through an alternative 11th rib resection while maintaining an extrapleural approach. Exposure was excellent, as judged by the neurosurgical team completing the repairs. Chest tubes were not used routinely, and all patients healed without complications. A major limitation of the 11th rib extrapleural approach to the thoracolumbar junction has been poor exposure. This problem is eliminated with the use of an abdominal self-retaining retractor system. With many potential advantages to this 11th rib exposure (less pain, fewer pulmonary problems, and better wound healing), we consider the 11th rib incision to be the approach of choice to the thoracolumbar junction and recommend renewed interest in this incision.

Young women with advanced aortoiliac occlusive disease: new insights.

We identified a group of 24 young (less than 50 years of age) women with isolated, premature atherosclerotic aortoiliac occlusive disease and attempted to identify distinguishing hemostatic characteristics. Most of these patients (62%) presented with acute thromboembolic events (blue toe syndrome, n = 6; macroemboli, n = 6; or aortoiliac thrombosis, n = 3). Aortoiliac reconstruction (aortoiliac endarterectomy, n = 10, aortobifurcation bypass grafts, n = 6; and percutaneous angioplasty, n = 4) was complicated by early thrombosis in 6 of 20 cases (30%), (1 of 10 endarterectomies, 4 of 6 bypass grafts, and 1 of 4 angioplasties). Fresh thrombus overlying an atherosclerotic plaque was a common finding at surgery. This observation and the relatively high incidence of thromboembolic events led us to hypothesize that a characteristic hemostatic profile might underlie the remarkably similar clinical presentations of these women. Levels of antiphospholipid antibodies (anticardiolipin antibodies and lupus anticoagulant), plasminogen activator inhibitor-1, fibrinogen, antithrombin III, protein C, protein S, plasminogen, prothrombin fragment F1 + 2, and D-dimer were determined for these young women and for 21 age-matched white female control subjects without vascular disease and nine white male patients with aortoiliac occlusive disease (mean 61 years, range 43 to 74 years). The incidence of anticardiolipin antibodies was 42% (8 of 19) in the female patients, which was significantly elevated (p = 0.028). The female (62.5%) and male (100%) patients had significantly elevated D-dimer levels (p < 0.001). Deficiencies of antithrombin III, protein C, and protein S were rare. A unique pattern of premature aortoiliac atherosclerosis exists in some young women. Intra-arterial thromboembolic events are common at presentation and complicate surgical management. The role of antiphospholipid antibodies remains uncertain.

Can the NASCET technique for measuring carotid stenosis be reliably applied outside the trial?

PURPOSE: The North American Symptomatic Carotid Endarterectomy Trial (NASCET) and the Asymptomatic Carotid Artery Study (ACAS) both confirmed the effectiveness of carotid endarterectomy for preventing stroke in patients who have significant carotid stenosis. A uniform technique for measuring carotid stenosis from an arteriogram (% stenosis = [1 - minimum residual lumen/normal distal cervical internal carotid artery diameter] x 100) was used in both trials, with reproducibility internally validated. The reliability of this measurement when used outside the trials for defining carotid stenosis has not been validated. Imprecise calculation of carotid stenosis can result in a 50% overestimation of significant carotid disease and potential overuse of carotid surgery. This is a prospective study of the reliability of carotid stenosis measurements performed by practicing physicians of different specialties and different levels of clinical experience. METHODS: Two vascular surgeons and two interventional radiologists (one resident and one staff member per specialty), blinded to results, calculated the percent stenosis from 219 consecutive arteriograms performed to evaluate extracranial carotid artery occlusive disease; 72 random films were reread by each individual. The interpretations were grouped as < 60% or > or = 60% stenosis (ACAS) and as < 30%, 30% to 69%, and > or = 70% stenosis (NASCET). Interobserver and intraobserver agreement were analyzed with the kappa statistic and Pearson correlation coefficients. RESULTS: Interobserver reliability in categorizing carotid stenosis revealed excellent agreement for both ACAS (kappa = 0.825 to 0.903) and NASCET groups (kappa = 0.729 to 0.793). Interobserver correlation coefficients ranged from 0.91 to 0.95. Intraobserver agreement was also highly reproducible for both the ACAS (kappa = 0.732 to 0.970) and NASCET categories (kappa = 0.634 to 0.805). Intraobserver correlation coefficients ranged from 0.89 to 0.95. CONCLUSION: The NASCET technique for quantification of carotid stenosis can be easily learned by physicians and reliably implemented for appropriate identification of candidates for carotid endarterectomy.

A technique for the creation of long autogenous tissue arterial patches.

An endarterectomized segment of an occluded artery (e.g. superficial femoral artery), is an alternative autogenous material for patch angioplasty which preserves the continuity of the saphenous vein. A technique of incising endarterectomized segments of superficial femoral artery in a spiraled manner is presented which allows for the creation of long autogenous tissue patches. A spiral is drawn on the exterior of a harvested arterial segment which is either 1 cm, 7 mm or 5 mm in width. When incised along the spiral, the length of the resulting elliptical patch will be two, three, or four times, respectively, the length of the original artery segment. The authors have used the technique to close extended profundoplasty in three patients and for construction of a patched distal anastomosis in two patients undergoing prosthetic femoropopliteal bypass grafting. There have been no early complications.

Candida arteritis: are GI endoscopic procedures a source of vascular infections?

A 53-year-old woman, 11 years after a renal transplant on chronic immunosuppression, presented with a sudden onset of a painless left groin mass. Ultrasound revealed a 3 cm common femoral artery pseudoaneurysm and a 3 cm saccular aneurysm of the infrarenal aorta. Operative repair was excision and patch angioplasty of the aortic aneurysm with internal iliac artery and interposition grafting of the femoral artery aneurysm with saphenous vein. Postoperatively, Candida albicans was identified in the aortic and common femoral arterial cultures. Candida infections often occur in patients with impaired cellular immunity due to seeding from urinary tract infections, vascular catheters, or manipulation of the gastrointestinal tract. Our patient, without any prior history of a fungal infection, had undergone a colonoscopy 3 weeks earlier. Without any other possible source being identified, the proposed mechanism for fungal entry into the vascular system was via the gastrointestinal tract, with seeding from the portal venous system. The exact medical and surgical management of these patients remains undefined, and a transplant vascular registry is really needed. However, immunocompromised solid organ transplant recipients undergoing gastrointestinal endoscopic procedures may be at a greater risk for the development of subsequent septicemia. Further reports are really needed to confirm the possible need in these patients for both periprocedural antibiotic and antifungal prophylactic coverage.

Primary Clostridium septicum aortitis: a rare cause of necrotizing suprarenal aortic infection. A case report and review of the literature.

A 74-year old woman sought medical attention for general symptoms of nausea, vomiting, and back pain. A computed tomographic scan showed gas in the wall of the descending thoracic and suprarenal aortas. Emergency thoracoabdominal exploration revealed a necrotizing infection of the thoracic aorta extending to the origin of the celiac axis. After surgery Clostridium septicum was identified in tissue culture. Surgical management consisted of in-situ graft replacement of the thoracoabdominal aorta. Three months later, a pseudoaneurysm developed at the distal anastomosis. The patient refused further surgery and died 3 days later. The cause of death was presumed to be a ruptured mycotic aneurysm as a result of recurrent C. septicum infection. The relationship of C. septicum with occult gastrointestinal and hematologic malignancy has been documented. This patient represents the 10th reported case of C. septicum arteritis. Including the nine previous case reports of C. septicum arteritis, the mortality rate is 70%. When evaluating a patient with a mycotic aneurysm or aortitis, C. septicum should be considered. If it is found, a search should be carried out for an associated gastrointestinal or hematologic malignancy. Surgical repair should include extraanatomic revascularization and wide debridement of the infected field. Consideration should be given to lifelong antimicrobial therapy for this potentially fatal infection.

Proximity penetrating extremity trauma: the role of duplex ultrasound in the detection of occult venous injuries.

The diagnosis and management of occult vascular injuries caused by penetrating proximity extremity trauma (PPET) remains controversial. Over 18 months, we prospectively screened 37 patients (43 lower extremities) with PPET for occult arterial and venous injuries using noninvasive studies (physical examination, ankle-brachial indices, color-flow duplex ultrasonography (CFD)) and angiography (arteriography, venography). Eight isolated, occult venous injuries were detected (incidence, 22%). CFD detected seven of eight (88%) venous injuries. Venography was technically difficult to perform in this patient population and failed to detect four femoral-popliteal vein injuries. Major thromboembolic complications (pulmonary embolism, symptomatic deep vein thrombosis, venous claudication) occurred in 50% of the patients identified with femoral-popliteal vein injuries. Arterial injuries were detected in 4 of 42 (10%) extremities (arteriography, n = 3; CFD, n = 1) and were clinically benign. We conclude that following PPET, (1) isolated, occult venous injuries are common and are associated with significant complications and (2) CFD is useful for screening for occult venous injuries.

Delayed diagnosis of duodenal rupture.

BACKGROUND: Although duodenal rupture is usually diagnosed during the course of surgery for other injuries, a small portion of such injuries occur in isolation. In such cases, the significance of the clinical and diagnostic findings may not be appreciated for an extended period. The primary determinant of mortality in duodenal rupture is the presence of associated injuries, but delay in diagnosis is often a secondary factor. METHODS: A retrospective case review of 8 patients with isolated duodenal rupture that was diagnosed more than 24 hours following the injury. RESULTS: In 5 cases, physicians did not look for the occult injury. In 3, patients did not seek medical attention. Two patients were initially treated with primary duodenal repair and drainage with poor results. All patients were eventually treated with pyloric exclusion that resulted in no deaths and no duodenal fistulas. Three patients developed abscesses after pyloric exclusion. They were drained without difficulty. CONCLUSION: Pyloric exclusion appears to offer a satisfactory option for dealing with the inflammation and contamination that result from prolonged soilage by duodenal contents.