Non-cirrhotic and non-malignant acute extrahepatic portal vein thrombosis (PVT): short- and long-term results.

This observational cohort study reports the short- and long-term clinical outcomes of 31 patients admitted for acute non-malignant, non-cirrhotic portal vein thrombosis (PVT) over a 10-year period. Patients had a mean age of 43 years at admission and a mean duration of follow-up of 84 months. All patients were initially treated with anticoagulants. Complete recanalization occurred within 30 days after admission in 18 patients (58%), partially in nine patients (29%), and failed in four patients (13%). During follow-up, 10 patients (32%) had at least one episode of gastrointestinal bleeding. The probability of remaining bleed-free was 0.93 at 24 months and 0.61 at 48 months. Fundal varices were not controlled by endoscopic sclerotherapy, so all four patients underwent portosystemic shunt construction. To date, there has been no mortality. In conclusion, using a combination of different treatment options reduces the risk of death and late complications in patients with non-malignant, non-cirrhotic PVT.

Intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) in acute lower limb ischaemia.

For various reasons some patients are unable to undergo intra-arterial thrombolysis for acute limb ischaemia. This interventional case series study prospectively evaluated the effect of thrombolytic treatment with 100 mg recombinant tissue plasminogen activator (rt-PA), administered intravenously, in patients with acute thrombosis of the lower limb arteries and onset of symptoms within 12 h prior to treatment. During a 3-year period (2007-2009), 18 of 86 patients satisfied the inclusion criteria and were included in the study (age range 65-80 years; 11 women). Complete and partial thrombolysis was observed in eight (44.4%) and six (33.3%) patients, respectively. All patients experienced clinical improvement. There were no amputations during the 36-month follow-up period and no haemorrhagic complications in the first 30 days post-treatment. Five patients died (27.8%) during follow-up from unrelated causes. This small study demonstrated that thrombolytic treatment with intravenous rt-PA in selected patients with acute limb ischaemia is feasible.

The value of adjunctive vein patches to improve the outcome of femorodistal polytetrafluoroethylene bypass grafts.

PURPOSE: A non-randomised comparative study was carried out to determine whether an interposition vein patch improves the long-term outcome of infrapopliteal and distal PTFE bypass grafts. PATIENTS AND METHODS: A prospective study (1992-1999) was carried out between 2 groups of patients. The first group comprised 86 patients undergoing the same number of femoropopliteal or infrapopliteal bypass procedures between March 1992 and February 1999 at our institution. PTFE with modified interposition vein patch was used as bypass graft. The second group comprised 191 patients who received 216 autogenous vein bypass grafts in the same period. The third group consisted of 94 patients from a retrospective study between 1985-1992, in whom PTFE bypass procedures without interposition vein patches had been performed. The indication for surgery was critical lower limb ischemia in all groups. Primary, secondary and limb salvage rates were calculated using the life-table method. The life tables were compared with the log-rank test. RESULTS: Five-year primary, secondary and limb salvage rates for PTFE with interposition vein patches were 53.4%, 60.7% and 68% for below-knee popliteal, and 29.5%, 35.5% and 41% for infrapopliteal bypass grafts, respectively. Five-year primary, secondary and limb salvage rates for autogenous vein grafts were 78.9%, 82.3% and 84.2% for below-knee popliteal, and 51%, 54.7% and 75% for infrapopliteal bypass grafts, respectively. Five-year primary, secondary and limb salvage rates for PTFE grafts without interposition vein patches were 29.7%, 37.8% and 43.6% for below-knee popliteal, and 6.9%, 9.2% and 14.7% for infrapopliteal bypass grafts, respectively. Statistical analysis showed a significant difference in primary, secondary and limb salvage rates between the groups. CONCLUSION: The results of our study indicate that autogenous vein still remains the graft of choice for below-knee and infrapopliteal bypass reconstruction. Their long-term patency and limb salvage rates were significantly better compared with PTFE grafts, with or without interposition vein patches. When adequate autogenous vein is not available, the interposition of a vein patch considerably improves the long-term outcome of PTFE bypass grafts.

Role of arteriovenous shunting in venous ulcers--therapeutic implications.

Although the presence of arteriovenous communications in patients with chronic venous ulcers has been confirmed in several studies, their role in the pathogenesis of venous ulcers is still uncertain. They possibly do play an important role in the aetiology of chronic venous insufficiency. There is also substantial evidence to suggest that arteriovenous communications develop as a result of chronic venous hypertension. The question raised in this pilot study was whether the importance of arteriovenous shunts in the genesis of venous ulcer disease is such that their obliteration might lead to long-term healing. This clinical study was also designed to determine whether therapeutic microembolization of nutritive arterial branches to arteriovenous fistulas, found in patients with venous ulcers, facilitates healing of venous ulcers resistant to previous conservative and/or classical surgical treatment. From 1997 to 1999, 34 patients (22 women and 14 men, mean age 51.3 years) with chronic venous ulcer resistant to classical treatment were included in the study. Arteriovenous shunting was demonstrated by digital subtraction angiography in 31 patients (31/34 = 91%). The embolization procedure of muscular arterial branches feeding the arteriovenous shunts with microspirals and microparticles led to ulcer healing in 13 patients (13/31). The results suggest that the role of arteriovenous shunting in chronic venous ulceration resistant to classical treatment is more important than previously suggested, and that their microembolization might lead to complete healing.

Three-dimensional ultrasonography for the evaluation of atherosclerotic stenoses of the carotid trunk.

Three-dimensional ultrasonography is a significant novelty in neurosonology as it offers the possibility of an even more successful evaluation of atherosclerotic stenoses of the carotid trunk than previous ultrasonographic investigations. In 37 patients with signs of transitory ischemic attack and in 5 patients with reversible ischemic neurologic deficit we compared the findings of three-dimensional ultrasonography of carotid arteries on the neck with those of three-dimensional CT angiography. In 20 of these patients in which carotid thrombendarterectomy had been carried out, the findings of both diagnostic methods were also compared with the angiographic and operative findings. In 2 out of the total of 42 compared findings of three-dimensional ultrasonography, three-dimensional CT angiography and angiography of the carotid trunk, we assessed a difference in the evaluation of the degree of carotid stenosis while all other findings were in accordance as regards the evaluation of the degree of stenosis and plaque analysis. Of 20 operative findings, one showed insignificant deviations from the findings of both diagnostic methods. It is our opinion that three-dimensional ultrasonography is a reliable diagnostic method in evaluating atherosclerotic stenoses of carotid arteries. Every subtotal stenosis or internal carotid artery occlusion established by three-dimensional ultrasonography must be compared with three-dimensional CT angiography or classic angiography due to the objective possibility of false ultrasonographic interpretation and the significance of carotid thrombendarterectomy.

Carotid body tumour surgery. A report of seven patients.

The purpose of the present paper is to analyse diagnostic and therapeutic aspects of carotid body tumours. Seven patients with carotid body tumour underwent surgery at our department between 1982 and 1998. All of them had an asymptomatic cervical lateral mass. The preoperative evaluation included angiography in 7 patients, duplex scanning in 2 patients and computed tomography in one patient. Tumour excision was performed in 5. Carotid artery resection with the tumour was required in 2 patients and in both, interposition of a 5-mm polytetrafluoroethylene graft was performed. During the resection, temporary carotid shunt was required in one patient. Perioperative transcranial Doppler was used once; the use of a shunt during carotid artery resection was not required in the second case. All tumours were identified as carotid paragangliomas without evidence of malignancy. There was no mortality and no hemiplegia. After surgery, temporary cranial nerve dysfunction was noted in 2 cases. In the follow-up period of 2 to 14 years (mean, 7 years), no recurrent disease occurred. Patency of the grafts was good at 4 and 7 years after carotid artery reconstruction. We conclude that with non-invasive investigation and arteriography it is possible to obtain an early and precise diagnosis. The decision to perform simple tumour excision or additional arterial resection is based on diagnostic preoperative as well as intraoperative evaluation of the individual tumour. As demonstrated in our cases, after resection of the internal carotid artery a polytetrafluoroethylene graft may be used for carotid reconstruction. Early surgery is recommended because it minimises the risk of complications associated with large tumours.

Surgical aspects of fusiform and saccular extracranial carotid artery aneurysms.

The purpose of this paper is to analyse surgical aspects of aneurysms of the distal extracranial internal carotid artery. Nine cases of extracranial carotid artery aneurysm are reported. Five were fusiform, located at the carotid bifurcation, and four were saccular, confined to the internal carotid artery. An end-to-end plication technique and Dacron patch angioplasty were employed for all fusiform aneurysms. In three saccular lesions, resection and 4-mm polytetrafluoroethylene (PTFE) graft interposition were carried out. In one case with a high lesion, ligation of the carotid artery was performed. Ligation resulted in severe postoperative stroke and fatal outcome. One patient with a saccular lesion developed a transient ischaemic attack after the operation. In other patients no central neurological deficit was produced by the surgery itself. Transient cranial nerve damage occurred in four patients (two hypoglossal nerve: two superior laryngeal nerve). As demonstrated by these cases, synthetic material may be used in restoration of the carotid artery. It is concluded that, according to type, location of the aneurysm and adequacy of contralateral cerebral blood flow, selective management is necessary.

Air-to-surface missile wound of the thorax reconstructed with a polytetrafluoroethylene patch: case report.

A method of reconstructing a chest wall defect following non-guided air-to-surface missile injury is described. The wall defect was simply closed with a polytetrafluoroethylene patch. The high risk of infection following use of the described method is well recognized. No infection occurred in this case. It could be stated that under the exigencies of the moment the use of prosthetic material to reconstruct the chest is not invariably followed by infection. However, when the patient is stable this latter problem can then be addressed by a variety of standard methods. It is concluded that the described method is particularly suitable in war circumstances, when it is usually necessary to attend to a large number of patients in a short period of time.

[Reconstruction of foot arteries after injury in arterial occlusive disease]. / Rekonstruktion der Fussarterien nach Verletzung bei AVK.

At the Maribor Teaching Hospital two elderly with progressive atherosclerotic disease below the knee were treated between 1986-1992 for open fracture of ankle joint and pedal arterial trauma. The only patent atherosclerotic vessel (dorsal artery of the foot) that was disrupted was reconstructed in both cases by interposition of a part of the great and small saphenous vein in one case each. A termino-terminal anastomosis with a long, triangular patch was used, fixed with interrupted sutures. The fractures were stabilized with external fixators. Both extremities were saved.