Multiple arterial thromboses associated with anabolic androgenic steroids.

The use of supraphysiological doses of anabolic androgenic steroids can have serious side effects. This article reports the case of a young man who suffered potentially life-threatening arterial thromboses following the use of these drugs.

Jejunal free flap for reconstruction of pharyngeal defects in patients with head and neck cancer-the Birmingham experience.

We retrospectively audited operative complications, success of flaps, and speech and swallowing outcomes in patients with head and neck cancer who had reconstruction with jejunal free tissue transfer to the pharynx. A total of 104 patients had jejunal free flaps between 1987 and 2009 at University Hospital, Birmingham. Management was by a multidisciplinary team, and the same vascular surgeon did all the anastomoses. We investigated the relations between patients, operative factors, and postoperative complications, and noted the ischaemic time of the flaps and coexisting conditions of the patients. Outcomes measured included initial and final survival rates of flaps, donor and recipient site complications, and speech and swallowing outcomes on discharge and up to 2 years postoperatively. Of the 104 patients, 14 (13%) had initial flap complications but overall flap survival was 97%. A total of 11 (11%) patients developed a fistula at a mean of 15 days postoperatively and 11 (11%) had minor donor site complications. A total of 95 (91%) were able to resume oral diet on discharge. Of the 44 who were followed up on discharge, 32 (73%) were able to maintain oral intake at 2 years and 31 (70%) could use their voice in everyday situations. The jejunal free flap enables the tumour to be removed, and reconstruction and restoration of function to be done in a single operation using tissue that is versatile. The operation is associated with low morbidity at the donor and recipient sites, and results in good speech and swallowing outcomes. The flap can also be used to reconstruct pharyngolaryngeal defects.

Cessation of epilepsy in an 8-year-old girl following removal of carotid body paraganglioma.

We present a case of an 8-year-old girl with established focal epilepsy, whose fits resolved permanently after excision of a carotid body paraganglioma.

Iliofemoral pulsion endarterectomy.

We present our experience with a technique of endarterectomy for use in patients with iliofemoral occlusive disease, in which the atheromatous plug is extruded from the intact artery by external manipulation (pulsion). A retrospective review of consecutive patients who underwent surgical iliofemoral pulsion endarterectomy (IFPE) in two vascular surgery units between 1998 and 2006 was performed. Primary and secondary graft patency, limb salvage, and patient survival rates were determined using Kaplan-Meier methods. Fifty-eight IFPEs were carried out successfully on 54 patients (36 men, 18 women, median age 66 years) presenting with critical limb ischemia (n=23), with claudication (n=29), or in conjunction with abdominal aortic aneurysm repair (n=6). Mean (range) follow-up was 17 months (1-69). During this period six patients (all male, mean age 64 years) underwent iliofemoral bypass using a prosthetic graft when the iliac arteries were found unsuitable for endarterectomy because of hypoplasia or heavy calcification. Two-year cumulative primary patency of IFPE was 95%, secondary patency 100%, limb salvage 98.5%, and patient survival 73%. This modification of iliac endarterectomy is a relatively simple and safe technique that eschews prosthetics and offers a durable solution for the majority of patients with extensive iliofemoral occlusive disease.

Surgical versus endovascular reconstruction for chronic mesenteric ischemia: a contemporary UK series.

OBJECTIVE: To assess the outcome of surgical (SR) and endovascular (ER) reconstruction for chronic mesenteric ischemia (CMI). METHODS: Retrospective review of consecutive patients who underwent SR or ER for CMI in 3 UK vascular surgery units between 1996 and 2006. Early (<30 days; technical success, morbidity, mortality, length of hospital stay) and late (>30 days) outcomes (symptom recurrence, vessel/graft patency, reintervention, mortality) were assessed. RESULTS: A total of 27 patients underwent 32 reconstructions (SR = 17, ER = 15). A total of 44 of 56 (79%) diseased arteries underwent SR (n = 26; bypass = 24, reimplantation = 2; occlusion = 16, stenosis = 10) or ER (n = 18; stenosis = 16, occlusion = 2). Perioperative mortality for SR and ER was 6% and 0%, respectively (P > or = .99). Hospital stay was shorter following ER (mean, 4.3 vs. 14.2 days, P = .0003). Mean (range) follow-up for SR and ER was 34 (1-94) and 34 (0-135) months, respectively. At 2 years, SR demonstrated superior secondary patency (100% vs. 65%) and clinical patency (100% vs. 73%). CONCLUSIONS: Surgical mesenteric reconstruction is associated with significantly longer hospital stay, but superior long-term outcome compared to endovascular reconstruction.

Modified trapdoor exposure for open repair of brachiocephalic artery branch injury: case report.

Central venous catheterization is associated with a wide spectrum of vascular complications, including inadvertent arterial puncture. We describe 2 cases of successful open surgical repair of iatrogenic cervicothoracic arterial injuries secondary to central venous catheterization. In both patients, a novel transmanubrial approach was incorporated to expose and control the brachiocephalic artery.

Randomized trial comparing Quixil surgical sealant with Kaltostat hemostatic dressing to control suture line bleeding after carotid endarterectomy with ePTFE patch reconstruction.

Following carotid endarterectomy (CEA), patch angioplasty provides a significant reduction in the risk of perioperative complications. The expanded polytetrafluoroethylene (ePTFE) patch is strong, is resistant to infection, and has low thrombogenicity; but it remains unpopular because of its tendency of prolonged bleeding at the suture line. We aimed to investigate whether the application of Quixil sealant to the suture line could improve the time to achieve hemostasis and reduce local blood loss when compared to a standard topical hemostat Kaltostat. A prospective, randomized trial of 20 patients undergoing CEA was undertaken. Patients were randomized to receive either Quixil sealant (treatment group) or topical Kaltostat (controls) as a hemostatic agent to the patch suture line. Hemostasis was defined as no bleeding at the suture line for 1 minute. Statistical analysis was performed using the Mann-Whitney test. The two groups had a similar age and sex distribution. The mean age was 71 years, and there were seven men and three women in each group. The time to achieve hemostasis was significantly lower in the Quixil group (median 2.5 minutes, range 1-4 minutes) compared to the controls (median 17 minutes, range 7-59 minutes) (p < 0.001). Blood loss after clamp release was also significantly reduced in the Quixil group; median 24.5 ml (range 5.5-105.0 ml) versus 203 ml (range 54.5-817.0 ml) (p < 0.001). This study has demonstrated that Quixil human surgical sealant is an effective sealant of ePTFE patch suture holes and does not compromise the patch repair. It could be used during other vascular procedures involving ePTFE.

In situ revascularization with silver-coated polyester grafts to treat aortic infection: early and midterm results.

PURPOSE: In this prospective study we analyzed the immediate and midterm outcome in patients with abdominal aorta infection (mycotic aneurysm, prosthetic graft infection) managed by excision of the aneurysm or the infected vascular prosthesis and in situ replacement with a silver-coated polyester prosthesis. METHODS: From January 2000 to December 2001, 27 consecutive patients (25 men, 2 women; mean age, 69 years) with an abdominal aortic infection were entered in the study at seven participating centers. Infection was managed with either total (n = 18) or partial (n = 6) excision of the infected aorta and in situ reconstruction with an InterGard Silver (IGS) collagen and silver acetate-coated polyester graft. Assessment of outcome was based on survival, limb salvage, persistent or recurrent infection, and prosthetic graft patency. RESULTS: Twenty-four patients had prosthetic graft infections, graft-duodenal fistula in 12 and graft-colonic fistula in 1; and the remaining 3 patients had primary aortic infections. Most organisms cultured were of low virulence. The IGS prosthesis was placed emergently in 11 patients (41%). Mean follow-up was 16.5 months (range, 3-30 months). Perioperative mortality was 15%; all four patients who died had a prosthetic graft infection. Actuarial survival at 24 months was 85%. No major amputations were noted in this series. Recurrent infection developed in only one patient (3.7%). Postoperative antibiotic therapy did not exceed 3 months, except in one patient. No incidence of prosthetic graft thrombosis was noted during follow-up. CONCLUSION: Preliminary results in this small series demonstrate favorable outcome with IGS grafts used to treat infection in abdominal aortic grafts and aneurysms caused by organisms with low virulence. Larger series and longer follow-up will be required to compare the role of IGS grafts with other treatment options in infected fields.

Surgery of popliteal artery aneurysms: a 12-year experience.

BACKGROUND: Management of asymptomatic popliteal aneurysm is controversial, and the prognosis for acutely thrombosed aneurysm is notoriously poor. We evaluated the management and outcome for popliteal aneurysm. PATIENTS AND METHODS: A retrospective review of all patients with popliteal aneurysm between 1988 and 2000 was carried out. Fifty-two limbs were operated on in 41 patients. Data collected included findings at presentation, operative details, graft patency, limb salvage, complications, and 30-day mortality. RESULTS: Initial findings included acute ischemia (n = 14), no symptoms (n = 29), acute rupture (n = 2), chronic ischemia (n = 5), and symptoms of nerve or vein compressive (n = 2). All patients with symptomatic aneurysms and 22 patients with asymptomatic aneurysms (21 larger than 2 cm in diameter, 1 with thrombus at duplex ultrasound scanning) underwent surgery as first-line treatment. Of the 7 patients with asymptomatic aneurysm managed with surveillance with duplex ultrasound scanning, acute ischemia developed in three, 1 aneurysm ruptured, compressive symptoms developed in 1, and 2 remained asymptomatic but required surgery because of aneurysm enlargement (>2 cm). Of the 17 patients with acute ischemia, 13 had neurologic signs and underwent immediate thromboembolectomy (trifurcation alone in 8, ankle-level arteriotomy in 4) and bypass grafting (n = 12) or inlay grafting (n = 1), and the other 4 underwent intra-arterial thrombolysis initially. Of these 4 procedures, 2 were successful and had elective surgery; the other 2 required urgent surgery because of secondary distal embolism and failure of recanalization. Thirteen of the 17 grafts were to the crural vessels. Bypass grafting (medial approach) was used in 16 of the 17 patients with acute ischemia, all 5 patients with chronic ischemia, and the 8 patients with no symptoms. An inlay technique (posterior approach) was used in 16 patients with no symptoms, the 3 patients with symptoms of nerve or vein compression, and 1 patient with acute ischemia. The distal anastomoses were to the below-knee popliteal artery in 35 patients and the crural arteries in 15 patients, using autologous vein. Two of the patients with rupture underwent ligation alone, the other undergoing bypass grafting in addition. The overall 5-year primary patency rate was 69%, secondary patency rate was 87%, and limb salvage rate was 87%. Limb salvage was achieved in 14 of the 17 patients with acute ischemia. Patients with asymptomatic aneurysms had better secondary graft patency (100%) compared with symptomatic aneurysms (74%; P <.01). Acute ischemia, technique used, and crural artery grafts were not predictors of graft failure with either univariate or multivariate analysis. Symptomatic aneurysms were associated with more postoperative complications and greater 30-day mortality (4 of 28 vs 0 of 24). CONCLUSION: Thromboembolectomy followed by crural bypass grafting is an effective treatment for popliteal aneurysm with severe acute limb ischemia. Outcome is better with surgical management of asymptomatic popliteal aneurysm compared with symptomatic aneurysm.

Composite sequential grafts for femorocrural bypass reconstruction: experience with a modified technique.

BACKGROUND: To evaluate the efficacy of a modification of the composite sequential femorocrural bypass graft that we adopted in 1985, a retrospective case-note study was undertaken. The grafts combined a prosthetic femoropopliteal section with a popliteal to crural section with autologous vein, linked via a common intermediate anastomosis sited on the above-knee popliteal artery. PATIENTS AND METHODS: Between 1985 and 2000, 68 grafts of this type were constructed in 65 patients with critical ischemia of the lower limb and insufficient autologous vein for construction of an all venous bypass. Reasons for insufficient long saphenous vein included previous lower limb bypass in 33 cases, phlebitis in 16 cases, venous hypoplasia in eight cases, and previous varicose vein surgery in seven cases. Distal anastomoses were carried out to the peroneal artery in 26 cases, the anterior tibial artery in 17 cases, the posterior tibial artery in 17 cases, and the pedal arteries in eight cases. Sources of vein included the long saphenous vein in 26 cases, the arm vein in 38 cases, and the short saphenous vein in two cases. In 22 limbs (32%), angiography had shown an occluded segment of above-knee popliteal artery, and in these cases, local popliteal disobliteration was performed to receive the composite anastomosis and to provide additional outflow. RESULTS: The 2-year cumulative primary patency, secondary patency, and limb salvage rates were 68%, 73%, and 75%, respectively. Localized popliteal disobliteration did not compromise graft patency (P =.07, with log-rank test). CONCLUSION: In the absence of sufficient autologous vein, patients needing bypass to crural arteries can be offered reconstruction with composite sequential grafting with satisfactory results. Furthermore, an occluded above-knee popliteal segment is not a contraindication for composite sequential bypass reconstruction.