Carotid thromboendarterectomy for recent total occlusion of the internal carotid artery.

BACKGROUND: The efficacy of emergency carotid thromboendarterectomy (CTEA) for acute internal carotid artery (ICA) thrombosis has been questioned. We evaluated the use of CTEA in patients with recent ICA occlusion. METHODS: From August 1989 to December 1999 patients who underwent urgent CTEA for recent ICA thrombosis were retrospectively evaluated. Patient data analyzed included age, sex, comorbid risk factors, diagnostic evaluation, operative procedure, and long-term follow-up with clinical assessment and carotid duplex scan. Neurologic status was evaluated with the Modified Rankin Scale (MRS) before the operation, immediately after the operation, and at 3- to 6-months' follow-up. RESULTS: Twenty-nine patients underwent emergency ipsilateral CTEA for acute ICA thrombosis over the last 10 years. The average age of the patients was 69.9 +/- 1.7 years, and 66% were men. Patient risk factors included diabetes (7 [24%]), hypertension (21 [72%]), coronary artery disease (8 [29%]), and history of tobacco abuse (20 [69%]). Presenting symptoms included cerebrovascular accident (7 [24%]), transient ischemic attack (nonamaurosis) (10 [34%]), crescendo transient ischemic attack (7 [24%]), stroke in evolution (2 [7%]), and amaurosis fugax (3 [10%]). Diagnostic evaluation included computed tomographic scan (29 [100%]), magnetic resonance imaging/magnetic resonance angiography (4 [14%]), duplex scan evaluation of the carotid arteries (23 [79%]), and cerebral angiography (18 [64%]). Antegrade flow in the ICA was successfully established in 24 (83%) of 29 patients and confirmed with intraoperative angiography or duplex sonography. Postoperative morbidity included 2 hematomas (7%), 4 transient cranial nerve deficits (14%), and 1 conversion to hemorrhagic stroke (3.6%), which resulted in the only death (3.6%). MRS scores averaged 3.4 +/- 0.2 preoperatively. Follow-up averaging 74.1 +/- 21 months (range, 3-140 months) was obtained in 27 (93%) patients. Improvement or deterioration was defined as a change in MRS +/- 1. Immediately postoperatively, 14 (48%) patients were improved, 2 (7%) deteriorated, and 13 (45%) had no change. At 3 to 6 months, 20 (74%) of 27 patients were improved, seven (26%) had no change, and none deteriorated. Of patients with successful CTEA, 23 (96%) of 24 had a patent ICA on follow-up duplex scan evaluation, and there was no evidence of recurrent ipsilateral neurologic events at an average of 49 months. CONCLUSION: These data support an aggressive early surgical intervention for acute ICA thrombosis in carefully selected patients. In the previous decade we reported a 46% success rate for establishing antegrade flow in the ICA long term. Data from this decade show a 79% (P =.0114) success rate for establishing antegrade flow long term in all patients undergoing emergency CTEA. New and improved imaging modalities have allowed better patient selection, resulting in improved outcomes.

Rare case of left-sided ureteroduodenal fistula.

BACKGROUND/AIMS: Ureteroduodenal fistulas are rare and only 11 cases have been reported in the literature since 1918. Diagnosis requires careful observation of symptoms. METHODS: The case presented demonstrates a 68-year-old female with left-sided ureteroduodenal fistula confirmed by CT scan. A duodenal fistula was localized and an atrophic left kidney was identified and repaired. RESULTS: Nephroureterectomy was performed and an omental patch was used for the repair. No complications were encountered during the postoperative course. CONCLUSIONS: Recurrent chronic urinary tract infection, pyuria and hematuria can indicate this rare disease. Early testing and detection can improve the chances of renal preservation.

Infectibility of endovascular stents following antibiotic prophylaxis or after arterial wall incorporation.

BACKGROUND: Case reports of endovascular stent infection have been accumulating in the last several years. We sought to determine if prophylactic antibiotics would prevent stent/artery complex infections in a swine model if given before a bacterial challenge at the time of stent placement and 4 weeks following deployment. We also investigated whether arterial wall incorporation protected the stent against infection without antibiotic prophylaxis. METHODS: Balloon expandable Palmaz stents were placed in the iliac arteries of 42 swine. At the same time, angioplasty was performed on the contralateral iliac artery as a control. In group A, prophylactic cefazolin was given to 12 swine at the time of stent deployment followed by an intraaortic bacterial challenge of Staphylococcus aureus. In group B, 10 swine received prophylactic cefazolin followed by intravenous S aureus 4 weeks after iliac stenting and angioplasty. In group C, 3 months following iliac stent placement and angioplasty an intravenous bacterial challenge was administered with S aureus. All swine were euthanized, and the iliac stent/artery complex and the contralateral angioplastied iliac artery were harvested and sent for culture and pathology. Experimental groups were compared with results from our previously published swine infection model using the Fisher's exact test. P values were considered significant if less than 0.05. RESULTS: Group A: Two of the 12 (17%) stent/artery complexes in the antibiotic treatment group had positive cultures. This compares with 7 of 10 (70%) in the control group (P = 0.016). In addition, there was one infection in an angioplastied vessel contralateral to one of the two stent infections. Molecular strain typing verified that the positive cultures were the same strain that was used to challenge the animals. No vessel thrombosis occurred in the stented arteries even in the presence of infection. Group B: One of 10 (10%) stented iliac arteries had a culture positive infection. This compares with 7 of 14 (50%) positive cultures in the control group (P = 0.04). In addition, one angioplastied vessel did have mild S aureus growth on culture. Both positive cultures were verified to be the same as the injected strain by molecular strain typing. There were no thrombosed or occluded vessels. Group C: One of 15 patent stents had growth of S aureus on culture and evidence of acute inflammation on histopathologic examination. The stent infection rate of 1 of 15 (7%) patent stents in this study was significantly less than the infection rates with bacterial challenge at placement (7 of 10, 70%; P < 0.01) and at 1 month postplacement (7 of 14, 50%; P = 0.0142). Five stents occluded without evidence of infectious cause. CONCLUSIONS: The results of this study support a recommendation that antibiotic prophylaxis should be used at the time of arterial stent placement and early after placement at times of anticipated bacteremia, but indefinite prophylaxis may be unnecessary due to arterial wall incorporation of the stent.

Nonsteroidal-induced benign strictures of the colon: a case report and review of the literature.

Colonic strictures are a rare complication reported to result from chronic use of sustained release formulations of indomethacin and diclofenac. Such strictures often present with associated mucosal ulceration and are thought to result from nonsteroidal antiinflammatory drug-induced alterations in enterocyte homeostasis. Strictures generally occur in the cecum, ascending, and proximal transverse colon with symptoms of occult blood loss, obstruction, changes in bowel habits, and rarely, perforation. The first reported case of a 69-year-old woman who developed recurrent colonic strictures with inflammatory changes and mucosal ulceration while taking Lodine (etodolac) is presented. A brief review of the relevant literature and suggested preventative therapies are discussed.

Endovascular stent infection with delayed bacterial challenge.

BACKGROUND: Reports of endovascular stent infection have recently been described. The purpose of this study was to determine if intravascular metallic stents in a swine model could become infected following a bacterial challenge given remote from the time of stent placement. METHODS: Balloon expandable metallic stents (Palmaz) were implanted in the iliac arteries of 14 swine. An angioplasty, without stent placement, was also performed in the contralateral iliac artery. An intravenous bacterial challenge with Staphylococcus aureus was given 4 weeks after stent placement. Euthanasia was performed 72 hours after the bacterial challenge. At the time of euthanasia, the iliac artery/stent complex and the contralateral angioplastied iliac artery were harvested and sent for microbiologic and pathologic analysis. RESULTS: Seven of the 14 stent/artery complexes were culture positive for S aureus whereas only one of the 14 angioplastied arteries was positive for S aureus (P = 0.03). On histologic examination, 6 of the 14 stent/artery complexes had evidence of acute inflammatory changes in the arterial wall. This compares with only 1 of 14 angioplastied arteries having evidence of inflammatory infiltrate in the arterial wall (P = 0.07). All 6 of the stent/artery complexes with inflammatory infiltrate were culture positive. CONCLUSION: In the swine model, intravascular metallic stents have the potential to become infected when a bacterial challenge is given 4 weeks after stent placement. Further studies evaluating the incidence of stent infections in humans are needed.

Tricuspid insufficiency after intracardiac migration of a Greenfield filter: case report and review of the literature.

We report the only known case of intracardiac vena cava filter migration resulting in valvular dysfunction. Echocardiographic evaluation documented the filter stenting open the tricuspid valve, with wide-open regurgitation. This case, as well as 22 cases of filter migration reported in the English literature, are used as a background to review prevention and treatment strategies.

Infection of endovascular stents in a swine model.

BACKGROUND: Percutaneous balloon angioplasty with intravascular metallic stent placement has rapidly gained popularity for the treatment of arterial occlusive disease. Although the incidence of vascular prosthetic infection is well described, the risk of infection following metallic stent placement is unknown. The purpose of this study was to determine if intravascular metallic stents could become infected following systemic bacterial challenge. METHODS: Balloon expandable metallic stents were implanted in the iliac arteries of 10 swine following balloon catheter angioplasty. A second angioplasty, without stent placement, was also performed in the contralateral iliac artery. A bacterial challenge with Staphylococcus aureus was then infused into the aorta immediately after stent placement. Group 1 (n = 5) was killed at 72 hours, and group 2 (n = 5) at 3 weeks. A third group (n = 5) underwent stent placement without bacterial challenge and was killed at 3 weeks. At the time of death, the stents were cultured, and both iliac arteries were submitted for pathologic examination. Arterial patency and evidence of systemic infection were also assessed. RESULTS: In the animals sacrificed at 72 hours (group 1), 80% had stent cultures with significant growth of S aureus; while at 3 weeks (group 2), 60% of cultures were positive. Of the stents placed without bacterial challenge (group 3), none had a positive culture at 3 weeks. In group 2, 40% of the stented arteries remained patent, while 100% of group 3 remained patent until sacrifice at 3 weeks. All of the stented arteries which were patent at 3 weeks were culture negative, while all those which were thrombosed were culture positive for S aureus. When compared to angioplasty alone, the presence of a stent was strongly associated with pathologic evidence of inflammation [93% versus 7%]. The quality of inflammation in the stented groups also differed. Ninety percent of the stented arteries in groups 1 and 2 had acute inflammation, compared to only 20% in group 3. The remainder of the stented arteries in group 3 had chronic inflammation or were normal. CONCLUSION: In the swine model, intravascular metallic stents have the potential to become infected. This is associated with acute inflammation of the arterial wall and vessel thrombosis. Further studies evaluating the incidence of stent infections in humans are needed.

Perineal and perirectal sarcomas: report of two cases.

PURPOSE: Perineal sarcomas are rare tumors that are typically of an extensive nature by the time of diagnosis. In this article, two case reports are followed by a brief review of different types of sarcomas that may occur in the perineal and perirectal region. STUDY PATIENTS: This study consists of two cases that are representative of the many types of perineal/perirectal sarcomas. PRINCIPLE CONCLUSIONS: Perineal and perirectal sarcomas are generally of poor prognosis mainly because of delayed diagnosis. Computed tomography and magnetic resonance imaging can be extremely useful to help assess these tumors. It is well known that the most important criterion for diagnosing leiomyosarcomas appears to be the presence of mitotic activity. Anorectal stromal tumors having five or more mitoses per 50 high powered fields are considered to be malignant. The mainstay of treatment is surgical excision with wide margins. Currently, chemotherapeutic and radiotherapy trials are under way.

Analysis of autogenous vein femoral-infrapopliteal bypass for limb salvage in the elderly.

The hypothesis that older patients undergoing femoral-infrapopliteal bypass have a similar outcome as a matched younger group of patients undergoing the same operation was tested. Seventy-six femoral-infrapopliteal autogenous saphenous vein bypasses for critical limb ischemia were performed from 1985 to 1990. By using the life-table method, the primary and secondary patency, limb salvage and survival rates are analyzed and compared for older and younger age groups. Forty cases (53%) were performed in an elderly group, defined as age 70 or older. At 4 years, there was no significant difference between age groups in limb salvage and patency rates. However, operative mortality for the older age group was 12%, compared with 0% in the younger group (P = 0.0004). Thus, femoral-infrapopliteal autogenous vein bypass can be performed with comparable limb salvage and patency rates for an older age group, but the risk of operative mortality appears to be increased with age.

Venous hemodynamic changes during laparoscopic cholecystectomy.

Virchow's triad of venous stasis, vessel wall damage, and hypercoagulability cites three factors that predispose to the formation of venous thrombosis. The pneumoperitoneum created during laparoscopic surgery results in an intraabdominal pressure that exceeds the pressure of venous blood return from the legs. This may alter venous hemodynamics enough to result in venous stasis in the legs, thus increasing the risk of thrombus formation. Duplex ultrasound was used to measure the diameter and venous flow volume of the common femoral vein during laparoscopic cholecystectomy. Measurements were obtained at three different times: after induction of anesthesia but prior to creation of pneumoperitoneum, during pneumoperitoneum, and after abdominal deflation but prior to reversal of anesthesia. After insufflation of the abdomen, the mean cross-sectional area of the common femoral vein increased (0.83 to 1.15 cm2; p = 0.0024) and the venous flow decreased (11.00 to 6.06 cm3/sec; p = 0.0008). After deflation of the abdomen, there was no significant change in cross-sectional area of the common femoral vein, but there was an increase in venous flow (6.06 to 9.94 cm3/sec; p = 0.0005). Abdominal insufflation during laparoscopic cholecystectomy results in dilation of and decreased flow in the common femoral vein. After deflation of the abdomen, flow in the vein returns to baseline levels.

Management options for hepatic artery aneurysms.

A 70-year-old woman underwent an elective sigmoid resection for chronic diverticulitis. On the third postoperative day she suddenly developed abdominal pain and hypotension after a coughing episode. Radiologic evaluation demonstrated the presence of a hemoperitoneum. A celiac arteriogram was obtained in an effort to determine the cause of the hemorrhage. Four aneurysms of the intrahepatic portions of the left and right hepatic arteries were found. These aneurysms were successfully treated using steel coil embolization. Surgery has traditionally been the "gold standard" treatment of this rare entity. Recent reports have demonstrated the utility of embolization in treating aneurysms of the hepatic arteries. This report reviews the current treatment options available in the management of hepatic artery aneurysms. Embolization of the aneurysms is recommended.

Subclavian steal syndrome. A review of 59 consecutive cases.

Subclavian steal syndrome results from reversal of flow through the vertebral artery from occlusion or stenosis of the proximal subclavian or brachiocephalic artery. The resulting "steal" phenomenon leads to the common symptoms of vertigo, syncope, and intermittent claudication of the involved upper extremity. However, these symptoms rarely, if ever, result in permanent neurological damage in and of themselves. A significant percentage of patients will have concomitant extracranial atherosclerotic disease present. Visual disturbances and transient paralysis occur more often in patients with coexistent carotid disease. Carotid artery endarterectomy should be performed first in these patients and will likely resolve all symptoms. Carotid subclavian by-pass using a PTFE graft conduit remains the procedure of choice for patients suffering from disabling symptoms and can be performed with low operative risk and morbidity with excellent long term results.

Bilateral popliteal vein aneurysms.

An 82-year-old man was admitted with a left hip fracture sustained in a fall. The fracture was surgically repaired. Ipsilateral leg swelling developed over the following 2 weeks. A lower extremity venous duplex scan demonstrated isolated dilatation of the popliteal veins in both lower extremities. Chronic thrombosis was noted in both popliteal veins at the level of this dilatation. Initial duplex scanning also revealed acute thrombus in the left popliteal, posterior tibial, and peroneal veins. A repeat scan 1 week later identified propagation of thrombus into the superficial femoral vein. Popliteal vein aneurysms, although rare, can cause significant morbidity and mortality. The literature is also reviewed.

Selective use of pelvic roentgenograms in blunt trauma patients.

This study was initiated to investigate the need for routine pelvic roentgenograms for all blunt trauma victims. Over a 2-year period, we prospectively studied patients referred to the trauma service in the level I trauma center at our institution who met the inclusion criteria. The patients were evaluated by physical examination and, if mentally alert and reliable, were included in the study. After inclusion into the study, a routine pelvic roentgenogram was performed to substantiate the results of our physical examination. All 125 patients included in the study were found to have normal results on pelvic roentgenograms. We conclude that alert, oriented and reliable patients involved in blunt trauma do not need a routine pelvic roentgenogram if the findings on physical examination are negative.

Early enteral feeding, compared with parenteral, reduces postoperative septic complications. The results of a meta-analysis.

This two-part meta-analysis combined data from eight prospective randomized trials designed to compare the nutritional efficacy of early enteral (TEN) and parenteral (TPN) nutrition in high-risk surgical patients. The combined data gave sufficient patient numbers (TEN, n = 118; TPN, n = 112) to adequately address whether route of substrate delivery affected septic complication incidence. Phase I (dropouts excluded) meta-analysis confirmed data homogeneity across study sites, that TEN and TPN groups were comparable, and that significantly fewer TEN patients experienced septic complications (TEN, 18%; TPN, 35%; p = 0.01). Phase II meta-analysis, an intent-to-treat analysis (dropouts included), confirmed that fewer TEN patients developed septic complications. Further breakdown by patient type showed that all trauma and blunt trauma subgroups had the most significant reduction in septic complications when fed enterally. In conclusion, this meta-analysis attests to the feasibility of early postoperative TEN in high-risk surgical patients and that these patients have reduced septic morbidity rates compared with those administered TPN.

Experience with physiologic amputation using the CryoCare Extremity Stabilization System (CESS).

Five years of experience gained with the CryoCare Extremity Stabilization System (CESS) were evaluated in this study. Twenty-one patients underwent freezing amputation. Five patients died before undergoing surgical amputation. Symptomatic relief, control of odor, decreased demand on nursing staff, and appreciation of the family make this approach valuable even when long-term survival is not anticipated. Ten patients who underwent freezing amputation subsequently underwent surgical amputation and were discharged. Six patients underwent freezing and surgical amputation but died prior to discharge. The patients selected for the freezer application were deemed to be prohibitive operative risks because they were experiencing systemic toxicity from their ischemic limb and underlying diseases. Six patients demonstrated myoglobinuria prior to freezing which cleared with CESS. The physiologic amputation allowed stabilization of medical problems including cardiac arrhythmias, congestive heart failure, sepsis, renal failure, diabetes, and respiratory failure. Freezing of an ischemic extremity allows delay in amputation enabling physicians to achieve maximal medical stabilization. It permits symptomatic relief in patients whose long-term survival is not anticipated. Physiologic freezing amputation should be included in the repertoire of all surgeons.