Tibial artery false aneurysm: uncommon result of blunt injury occurring during athletics.

Two young men presented with symptoms following lower extremity injuries sustained in the normal course of participation in sports. One played baseball while the other competed in Tae Kwon Do. One case presented with digital ischemia, the other developed a pulsating hematoma. Each came to angiography, and each proved to have a false aneurysm of a tibial artery. The tibial artery was ligated in each case, without further complications. The patient with digital ischemia was thought to have sustained microemboli, and also underwent lumbar sympathectomy.

Retroperitoneal nonresective staple exclusion of abdominal aortic aneurysms: clinical outcome and fate of the excluded abdominal aortic aneurysms.

PURPOSE: The purpose of this article was to prospectively study analyses outcome after staple exclusion of abdominal aneurysms with specific follow-up of the excluded aneurysm. Whether these data may predict behavior of aneurysms excluded from the circulation by transluminal grafting procedures is also addressed. METHODS: Staple exclusion of abdominal aneurysms with bypass via retroperitoneal incisions was performed in 100 consecutive patients undergoing elective procedures. Risk factors, clamp time, operative time, transfusions, length of stay, complications, platelets, fibrinogen, and fibrin split products were documented. Duplex imaging was performed quarterly for 1 year after exclusion and at least annually thereafter. Serial measurements of aneurysm size and evaluation for thrombosis was obtained. RESULTS: Aneurysm size averaged 5.5 cm. Risk factors included history of smoking (54%), history of heart disease (51%), hypertension (41%), hyperlipidemia (34%), and chronic obstructive pulmonary disease (25%). Clamp time averaged 51 minutes. Forty-eight required no intraoperative transfusion, and 19 needed only autologous blood; the average 24-hour transfusion was 313 cc. Length of stay averaged 11 days, with a median of 8 days, and correlated with age, aneurysm size, and risk factors. The 30-day mortality rate was 4%. Death was associated with longer operative and anesthesia times and with age and risk factors. As calculated by life-table analysis to 5 years, 96.8% of aneurysms thrombosed. No aneurysm expanded, became symptomatic, nor ruptured. Perioperative platelet, fibrinogen, and fibrin split product assays show no evidence of disseminated intravascular coagulation or consumptive coagulopathy. CONCLUSIONS: Staple exclusion and bypass of abdominal aneurysms as described in this study is safe and effective. There has been neither aneurysm expansion nor rupture, and the technique reliably leads to thrombosis of aneurysms without coagulopathy.

Venous conditions associated with pregnancy.

Pregnancy is associated with several changes in venous physiology. These include relaxation of venous wall tone and increased lower extremity venous pressure. As a result of these changes, varicose veins, spider telangiectasias, purpura, and other superficial findings may develop. Treatment of these conditions is conservative during pregnancy. As the changes in venous hemodynamics resolve over several weeks after delivery, partial or complete regression may occur. In cases where persistent abnormality persists well after delivery, more definitive therapy may be considered. Pregnancy is also associated with a mild hypercoagulable state, and there may be trauma to venous endothelium associated with delivery. Coupled with the relative stasis resulting from pelvic venous compression by the uterus and from decreases in venous tone, these changes cause an increased risk of deep vein thrombosis in late pregnancy and the peripartum period. Anticoagulation with heparin is required as coumadin and fibrinolytic agents are considered to be hazardous.

Venous dysfunction of late pregnancy persists after delivery.

Pregnancy is associated with DVT, pelvic thrombophlebitis, and lower extremity varicosities. Pelvic venous compression by the gravid uterus is blamed. A prospective controlled study using plethysmography was performed. Venous capacitance and outflow were measured at term, and at 1 week, 6 weeks and 3 months following delivery. Results show decreased venous capacitance and venous outflow at term pregnancy, no improvement 1 week after delivery, modest improvement at 6 weeks, and dramatic statistically significant improvement in both parameters by 3 months. The persistence of venous dysfunction for several weeks after delivery indicates that changes in venous function at term pregnancy are largely the result of factors other than pelvic venous compression by the gravid uterus.

Sartorius muscle coverage for the treatment of complicated vascular surgical wounds.

Sartorius muscle flaps were evaluated in 14 patients treated for complicated groin wounds related to vascular surgical procedures. Particular risk factors for poor wound healing were present in 8 patients, including diabetes, obesity, or poor nutrition in 3 patients; prior radiotherapy to the groin in 2; reoperative groin exposure in 3. Eleven of 14 patients had multiple indications for sartorius flap coverage, including hemorrhage in 5 patients, groin wound sepsis in 3, graft sepsis in 2, wound necrosis in 5, exposure of a reconstruction in 4, treatment of a lymphocele in 1, and treatment of groin irradiation in 2. Nine flaps were proximal sartorius segments rotated into the groin, four were distal muscle reflected into the groin, and one was a mobilized mid-portion of the muscle. Early successful wound healing occurred in all patients, but complications included muscle bed infection in 1 patient, late recurrence of lymphocele in 1, and recurrent groin sepsis in 1. Hemorrhage did not recur, and existing reconstructions were salvaged in all patients. The sartorius flap is a well-tolerated method for achieving autogenous tissue coverage for the problem groin wound, and there is no long-term functional deficit from anatomic loss of the sartorius muscle.

Lymphatic drainage from the groin following surgery of the femoral artery.

Lymphatic drainage from the surgical wound is uncommon after most surgical procedures. Little data regarding this problem is encountered in the American literature. The incidence of this complication is not established. Data are not available regarding speculative risk factors, including diabetes reoperative dissection, infection, and use of prosthetic materials. The likelihood secondary infection is not established. A review of 428 wounds following dissection of the femoral artery was undertaken, with analysis of resulting wound drainage. Lymphatic drainage occurred in 5% of groin wounds. Diabetes, infection of the operated leg or foot and use of prosthetic graft were associated with statistically insignificant increases in risk. Reoperation was associated with a statistically insignificant decrease in risk. Most drainage stopped spontaneously. In 40% of patients with drainage, protracted lymphorrhea contributing to morbidity and hospital stay resulted. This outcome was unlikely in the absence of prosthetic graft. Such patients may benefit from surgical exploration of the wound and ligation of lymphatic tissue. Graft infection was not observed. While infection was an infrequent secondary complication, bacteriologic monitoring and antibiotic therapy are essential in cases of prolonged drainage.

Hemodynamics of in situ vein bypass: the role of side branch fistulae.

Ten patients undergoing femoral-popliteal and femoral-tibial in situ saphenous vein bypass for limb salvage were studied to determine the effects of side branch arteriovenous fistulae on flow through the distal end of the graft into the outflow artery. Studies were performed intraoperatively with electromagnetic flow probes. Following completion of proximal and distal anastomoses, flow was established through the graft and measured through its proximal and distal ends. Side branches were then ligated, and flow through the distal end of the graft measured again. Papaverine was administered and flow measured once more. Measured flows were consistent with those observed in previous studies, as were changes in flow induced by papaverine. Results indicate statistically significant diversion of blood through the fistulae, and a statistically significant increase in distal graft flow accompanying ligation of side branch fistulae. These data support the practice of routine side branch ligation during in situ bypass grafting.

Primary lymphoma of the gastrointestinal tract.

Forty-six instances of gastrointestinal tract lymphoma are reviewed with attention to clinical features, diagnostic studies, surgical approach and adjuvant therapy. Gastrointestinal tract lymphoma may be present at any age in individuals with pain, abdominal mass or other abdominal findings, and all ulcers and other endoscopically accessible lesions require biopsy, without regard for roentgenologic or endoscopic appearance of benignity. Resection is recommended when cure is possible; adjunctive therapy is regarded as beneficial. There is a good prognosis for those patients surviving two to three years beyond diagnosis.

Mesenteric hematoma suggests rupture of visceral artery aneurysm.

A 61-year-old man with nonspecific abdominal pain appeared to have an intramesenteric hematoma by computed tomographic scan. He suffered catastrophic intraperitoneal hemorrhage from a mesenteric branch-artery aneurysm several days later. A mesenteric hematoma, which can be diagnosed noninvasively, suggests a bleeding visceral artery aneurysm, and such findings warrant angiography followed by abdominal exploration if the presence of a visceral artery aneurysm is confirmed.