Pattern and distribution of peripheral arterial disease in diabetic patients with critical limb ischemia (rutherford clinical category 4-6).

BACKGROUND: This study investigated the pattern and distribution of peripheral arterial disease in diabetic patients with critical limb ischaemia (CLI) and to stratify the findings according to the patients' risk factor profile, gender and age group. METHOD: We conducted a one-year prospective descriptive study (January 2014 to December 2014) at Groote Schuur Hospital, University of Cape Town. The research protocol and the informed consent were approved by the Institutional Review Board, and all subjects included in this study gave an informed consent. We included all diabetic patients over the age of 18 years with critical limb ischemia who had pre and post-intervention vascular imaging. The calculated minimum sample size was 63 limbs. We hypothesize that the proportions of arterial segment patency categories and the arterial foot arch status varies according to gender, age group and risk factor combinations in diabetic patients. The Null hypothesis (N0) assumes that the proportions of arterial segment patency categories and arch status are the same in diabetic patients irrespective of gender, age group and risk factor combination. The equality of distribution was analysed using the One Sample Chi-square test. Three risk factor combination groups were analysed: Group 1 (diabetes mellitus, hypertension, dyslipidemia), Group 2 (diabetes mellitus, hypertension, dyslipidemia, ex-smoker) and Group 3 (diabetes mellitus, hypertension, dyslipidemia, smoker). RESULTS: Seventy-one patients were analysed (38 females and 33 males). We recorded the patency grades (ranging from normal to occlusion) of arteries in all 3 lower extremity arterial segments (aortoiliac; femoropopliteal and tibioperoneal segments). Altogether the patency grades of 820 lower extremity arteries were recorded. Diabetics, collectively, were found to have more severe occlusive disease in the tibioperoneal segment (P < .001). Group 3 patients however, had more severe occlusive disease in the femoropopliteal segment compared to the other subgroups (P < .001). Group 1 and Group 2 patients had more severe occlusive disease in the tibioperoneal segment (P < .001). Females were more likely to have complete foot arches (22/37; P = .004) while males tended to have more incomplete foot arches (17/32; P = .048). CONCLUSION: Diabetic patients collectively have severe tibioperoneal occlusive disease. However, Group 3 patients tend to have disproportionately more occlusive disease in the femoropopliteal segment (P < .001). Diabetic female patients with CLI are more likely to have a complete arterial foot arch than males (P = .004).

Severe post-pancreatoduodenectomy haemorrhage: An analytical review based on 118 consecutive pancreatoduodenectomy patients in a South African Academic Hospital.

BACKGROUND: Bleeding after a major pancreatic resection, although uncommon, has serious implications and substantial mortality rates. AIM: To analyse our experience with severe post-pancreatoduodenectomy haemorrhage (PPH) over the last 7 years to establish the incidence, causes, intervention required and outcome. METHOD: All patients who underwent a pancreatoduodenectomy (PD) between January 2008 and December 2015 were identified from a prospectively maintained database. Data analysed included demographic information, operative details, anastomotic technique, histology, postoperative complications including pancreatic fistula and PPH, length of hospital stay, need for blood products and special investigations. Pancreatic fistula was classified according to the International Study Group of Pancreatic Surgery (ISGPS) classification. A modified ISGPS classification was used for PPH. RESULTS: One hundred and eighteen patients underwent PD during the study period of whom 6 (5.0%) died perioperatively. Twenty patients (16.9%) developed a pancreatic fistula and 11 patients (9.3%) had a severe PPH of whom one (9.1%) died. No patients had a severe bleed during the first 24 hours postoperatively. Four patients bled within the first 5 days and the remaining 7 after five days. Six patients bled from the gastroduodenal artery and were all preceded by a pancreatic fistula. Three of the 7 patients who bled late presented with extraluminal bleeding, 3 presented with intraluminal bleeding and 1 with a combination of both. Patients presenting in the first 5 days were all successfully managed either endoscopically or surgically. Five patients who presented beyond 5 days postoperatively were managed primarily with interventional angiography, either with coiling or deployment of a covered stent. Three patients who had radiological intervention developed a liver abscess or necrosis. CONCLUSION: Severe PPH is associated with substantial morbidity. Clinical factors including the onset of the bleeding, presentation with either extra and/or intraluminal haemorrhage, and the presence of a pancreatic fistula give an indication of the likely aetiology of the bleeding. A management algorithm based on these factors is presented.

Stent graft repair of subclavian and axillary vascular injuries: The Groote Schuur experience.

BACKGROUND: Trauma-related subclavian and axillary vascular injuries (SAVIs) are generally associated with high morbidity and mortality rates in the surgical literature. There is an emerging trend towards increasing use of stent grafts (covered stents) for repair, with evidence limited to small case series and case reports. OBJECTIVES: To report on the clinical and device-related outcomes of stent graft repair of trauma-related SAVIs at a single institution. METHODS: A retrospective chart review of all patients with trauma-related SAVIs requiring stent graft repair was performed. Outcome measures included technical success, mortality, amputation rate, device-related complications (early and late), and reintervention rates (early and late). RESULTS: A total of 31 patients was identified between June 2008 and October 2013 (30 males, 1 female). Mean age was 27.9 years (range 19-51). All 31 patients sustained a penetrating injury (93.5% stab, 6.5% gunshot injuries). There were 21 subclavian and 10 axillary artery injuries. Five patients (16%) were HIV-positive. Nine patients (29%) were shocked on presentation. Early results (30 days): There were no periprocedural deaths. Primary technical success was 83.9% (26/31). Five patients required adjunctive interventional or operative procedures. There were no early procedure-related complications, reinterventions or open conversions in this study. Overall, suboptimal results were seen in five patients (one type I endoleak and four type II endoleaks). Follow-up results (>30 days): Nineteen patients (61.3%) were available for follow-up. Mean duration of follow-up was 55.7 weeks (range 4 - 240). Overall stent graft patency was 89.5% (17/19). Four patients (21.1%) had an occluded stent graft. Stent graft salvage was possible in two patients. Three type II endoleaks were seen on follow-up. Late reinterventions were performed in five patients (26.3%). Conversion to an open procedure was not required in any patient. There was one late death and one major amputation of a stented limb in a patient who had sustained severe soft-tissue injuries during the follow-up period. CONCLUSION: Perioperative, early and intermediate results suggest that stent graft repair of select trauma-related SAVIs is relatively safe and effective. Axillary arteriovenous fistulas remain a particular challenge using this treatment modality. Larger prospective studies are required to define the utility of stent grafts for select trauma-related SAVIs better.

An unusual case of swab embolism.

Intravascular foreign body embolism is an exceptionally uncommon problem. We report on an unusual case of a surgical swab embolism which occurred during a thoracic surgical procedure.

Dysphagia lusoria: a case of an aberrant right subclavian artery and a bicarotid trunk.

Dysphagia Lusoria is dysphagia secondary to an aberrant right subclavian artery that has a retroesophageal course. Adachi and Williams categorized aortic arch anomalies, showing that the right subclavian artery arising in this fashion (as the final branch of the descending aortic arch) is one of the more common. However, this very rarely coexists with a bicarotid trunk. We present such a case as it is manifested in a 36-year-old lady complaining of marked weight loss and dysphagia. The diagnosis remained elusive until a CT scan of the chest was performed; angiography further delineated the pathology. It is believed that the combination of the common carotid origins with the retroesophageal course of the aberrant vessel more frequently accounts for symptoms in the absence of an aneurysm of the origin of the aberrant vessel. Several techniques to manage the aberrant vessel have been described in the literature, but we favoured open ligation and transposition to the right carotid artery.

Progressive human immunodeficiency virus-associated vasculopathy: time to revise antiretroviral therapy guidelines?

Cardiovascular abnormalities were appreciated early in the epidemic of the acquired immunodeficiency syndrome (AIDS), even before the aetiological agent, human immunodeficiency virus (HIV) was isolated and characterised. The aetiology and pathogenesis of cardiovascular disease in HIV infection is still the subject of intense speculation, and is likely multi-factorial. HIV affects every aspect of the cardiac axis, causing pericarditis, myocarditis, cardiomyopathy, coronary artery disease and microvascular dysfunction, valvular heart disease, pulmonary vascular disease and pulmonary hypertension, stroke and peripheral vascular disease. HIV-associated vasculopathy is an increasingly recognised clinical entity, causing high morbidity and increasing mortality in southern Africa, particularly from stroke and cardiovascular disease. HIV causes disease of the vascular tree, either by a direct effect on vascular or perivascular tissue, or indirectly via immune complex-mediated mechanisms, associated opportunistic infections and malignancies. As a result, highly active antiretroviral therapy (HAART) may have an important role in controlling disease progression. We report a case of histologically defined primary HIV vasculopathy in which the chance to start HAART was initially missed and in which the patient progressed to require bilateral amputations, but obtained disease quiescence upon commencement of HAART.

Other manifestations of HIV vasculopathy.

Descriptions of the numerous manifestations of human immunodeficiency virus (HIV) infection affecting almost every organ system have abounded in recent publications. Multiple radiological, clinical and postmortem reports have recorded the cerebral, pulmonary, cardiac, renal, rheumatological and gastrointestinal pathologies in HIV-infected individuals, ranging from the bizarre to the mundane. Large-vessel HIV-related vascular manifestations have previously been reported in the surgical literature. We describe and review the manifestations of HIV-associated vasculopathy as it pertains to the cerebral, cardiovascular, mesenteric and renal circulations.

Transmetatarsal amputation: three-year experience at Groote Schuur Hospital.

Transmetatarsal amputation (TMA) for peripheral vascular disease has the reputation of being an operation with a poor outcome. This retrospective study reviewed a 3-year consecutive series of TMA in diabetic and nondiabetic patients. All amputations performed for peripheral vascular disease at Groote Schuur Hospital from January 1999 to December 2002 were reviewed. Data were obtained from hospital records and operating theatre books. The following groups were defined for the purpose of this retrospective study: group 1, TMAs performed in diabetic patients; group 2, TMAs done in nondiabetic patients. Altogether, 43 TMAs were performed: 27 in group 1 and 16 in group 2. Perioperative mortality rates were 7% and 4%, respectively. Overall, the healing rate was 67%: 62% (17/27) in group 1 and 75% (12/16) in group 2. The median times to healing were 8 months in group 1 and 7 months in group 2. Toe pressure and the presence of advanced tibioperoneal disease influenced the outcome of TMA in diabetic patients. Transmetatarsal amputation with a healed stump provided our patients with good mobility. Prediction of healing after operation is unreliable. There was no statistical difference in outcome in diabetic (group 1) versus nondiabetic (group 2) patients.

Spontaneous arteriovenous fistula resulting from HIV arteritis.

Arteriovenous fistulas (AVFs) are uncommon and usually follow trauma or preceding arterial catheterization or puncture. Spontaneous AVFs are rare. A case of spontaneous AVF of the superficial femoral artery and vein in an HIV-infected patient is presented. Histologic examination of the artery showed features similar to those seen in HIV-related large-vessel aneurysms. It would appear that spontaneous AVF are part of the spectrum of macrovascular arteritis related to HIV infection.

Occlusive arterial disease in HIV-infected patients: a preliminary report.

OBJECTIVES: to preliminarily describe the clinical features and management of arterial occlusive disease in human immunodeficiency virus (HIV) infected patients. MATERIALS: twenty HIV positive patients with symptomatic large-vessel arterial occlusion treated by a tertiary vascular unit in a 3-year period. METHODS: retrospective review of clinical case records. RESULTS: patients were noted to be young (median age 37 years), with preponderance of males. Twelve patients had evidence of advanced HIV infection. All patients had critical ischaemia, involving the upper limbs in four and the lower limbs in 16. Coagulation abnormalities were noted in two cases. Operative intervention in 18 patients included revascularisation in seven. Thrombotic occlusion of normal-looking arteries was noted. Arterial biopsy revealed leucoIcytoclastic vasculitis indicative of HIV arteritis in three of five cases examined. CONCLUSIONS: initial experience with large-vessel occlusive disease in HIV positive patients suggests an underlying arteritic aetiology, with clinical and pathological features distinct from atherosclerosis. Further in-depth study is necessary to clarify the pathophysiological basis thereof.

Clinical profile of HIV-related aneurysms.

OBJECTIVES: to describe the clinical features, management, outcome and laboratory features of human immunodeficiency virus (HIV)-related aneurysms. MATERIALS: twenty-eight HIV positive patients with arterial aneurysms treated at a single university teaching hospital in a 6-year period. METHODS: case review of clinical records and laboratory findings. Specimens from patients surgically treated submitted for microbiological and histological examination. RESULTS: ninety-two aneurysms were seen (range 1-10 per patient) in a young patient population (median age 30 years). Nineteen patients had evidence of advanced HIV infection. Aneurysms were atypically located and most frequently involved the carotid (24), superficial femoral (21) and popliteal (nine) arteries. Twenty-five of the 31 symptomatic aneurysms were treated surgically. Surgical intervention comprised arterial reconstruction for 19 and aneurysm resection and ligation for the remainder. Histological examination revealed distinctive arteritic features. There were two treatment-related deaths, with short-term post-operative outcome being otherwise favourable. CONCLUSIONS: HIV related aneurysms are characterised by their predilection for young patients, multiplicity, atypical location and their distinct histological features. Their increasing frequency reflects the unchecked advance of the HIV epidemic.

Spontaneous carotid artery aneurysms.

BACKGROUND: Spontaneous carotid artery aneurysms are infrequently reported, and are almost always non-atherosclerotic. METHODS: The records of 29 patients with a spontaneous carotid aneurysm treated in an academic vascular unit between 1990 and 1998 were reviewed. RESULTS: All 29 patients were black South Africans; three had bilateral aneurysms. There were 24 men and five women, of mean age 35 (range 13-62) years. Some 25 aneurysms involved the common carotid artery, 12 of which affected the bifurcation, and seven were located in the internal carotid artery. Twenty-five aneurysms were managed surgically, four of which were ligated owing to sepsis. Histo- logical evaluation showed human immunodeficiency virus-related arteritis in four, tuberculous aneurysms in ten, Takayasu's arteritis in two, atherosclerosis in three and non-specific chronic inflammation in four patients. Microbiological examination was negative in all but one patient who had Salmonella sp. cultured. Outcome was generally favourable, but one patient died from massive hemispheric infarction. There were no other new neurological deficits. CONCLUSION: Carotid aneurysms pose a considerable surgical challenge but are amenable to operative intervention with good result. Ligation appears to be well tolerated in this group of predominantly non-atherosclerotic aneurysms.