Intraoperative intra-arterial urokinase therapy after failed embolectomy in acute lower limb ischemia.

BACKGROUND: Aim of this study is to evaluate the use of intraoperative intra-arterial urokinase infusion (IIUI) in overcoming residual thrombi after thromboembolectomy in acute lower limb ischemia. DESIGN: retrospective study over a 3-year period. SETTING: University affiliated hospital. PATIENTS: 21 patients with acute lower limb ischemia who underwent IIUI after embolectomy (18 transfemoral, 3 transpopliteal) had failed to achieve adequate distal perfusion. Postoperatively, all patients were maintained on full dose heparinization. MAIN OUTCOME MEASUREMENTS: complete or partial clot lysis on post-IIUI angiography; restoration of pedal pulses and a viable leg at discharge. RESULTS: Angiographically, complete and partial lysis was demonstrated in 14 and 3 patients, respectively. Two patients with prolonged ischemia required fasciotomy. One of these eventually had an amputation. Altogether, limb amputations (1 above knee, 2 below knee) were necessary in 3 patients. The angiographic appearance of lysis correlated well with the restoration of pedal pulses and/or limb viability. One patient died of myocardial infarction 3 days after the procedure. Postoperatively, there were 5 (24%) wound hematomas of which 1 required surgical exploration. Over a mean follow-up period of 8 months (range 1-16), limb salvage was sustained in the 17 patients with successful angiographic lysis. CONCLUSIONS: IIUI is an effective therapeutic adjunct to failed embolectomy in acute lower limb ischemia. Use of this procedure is recommended as part of the routine management in such cases.

Vascular surgical society of great britain and ireland: isolated femoral profundoplasty with endarterectomized superficial femoral artery for limb salvage in the elderly

BACKGROUND: This longitudinal observational study was designed to show that isolated profundoplasty to relieve a significant stenosis is a valid procedure for limb salvage in the elderly. METHODS: Twenty-seven patients with critical limb ischaemia underwent isolated profundoplasty using endarterectomized superficial femoral artery as an arterial patch. Nineteen patients were men. The mean age was 72 (range 65-79) years. All patients had rest pain with or without an ischaemic foot ulcer or pedal gangrene. RESULTS: There was no operative death or immediate operative failure. All 27 limbs were improved, with relief of rest pain, healing of ulcers and healing after minor foot amputations. The 27 patients underwent a mean of 30 (range 12-45) months of periodic observation in an outpatient clinic, either to the present time or until death. Two patients required late amputations and one a femorodistal bypass. CONCLUSION: Isolated profundoplasty has a place in leg revascularization in the high-risk elderly patient. Endarterectomized superficial femoral artery as a patch has the advantages of almost universal availability and anatomical convenience.

Penetration of clindamycin and metronidazole into inflamed appendiceal tissue.

OBJECTIVE: To calculate the penetration of clindamycin and metronidazole into inflamed appendiceal tissue. DESIGN: Prospective study. SETTING: Teaching hospital, Israel. SUBJECTS: 20 Consecutive men and women operated on for acute appendicitis. INTERVENTIONS: Appendicectomy. Each patient was given three intravenous injections of gentamicin 80 mg combined with either clindamycin 600 mg or metronidazole 500 mg immediately before operation over a period of 15 minutes. MAIN OUTCOME MEASURES: Serum and tissue concentrations of the antibiotics. RESULTS: There was no significant difference between the mean serum concentrations of the drugs (clindamycin 17.86 micrograms/ml and metronidazole 9.75 micrograms/ml) but the mean tissue concentrations of clindamycin (10.41 micrograms/g in the base and 9.86 micrograms/g in the tip of the appendix) were significantly higher than those of metronidazole (5.65 micrograms/g in the base and 5.89 micrograms/g in the tip; p = 0.02 and p = 0.05, respectively). Tissue concentrations of clindamycin and serum concentration of both drugs were more than twice their MIC90. The tissue concentrations of metronidazole were close to its MIC90. CONCLUSIONS: Clinical trials are necessary before any conclusion about therapeutic superiority of one or other agent can be drawn.

Penetration of ceftriaxone and cefoperazone into bile and gallbladder tissue in patients with acute cholecystitis.

The penetration of ceftriaxone and cefoperazone into bile and gallbladder tissue was prospectively studied in 21 adult patients undergoing early surgery for acute cholecystitis. Comparable tissue, bile, and serum concentrations of the drugs were demonstrable; however, significantly fewer preoperative doses of ceftriaxone were required for adequate perioperative treatment. In view of its higher serum half-life and superior antibacterial activity toward common biliary pathogens, ceftriaxone appears to be a useful drug for the perioperative management of acute cholecystitis.