Coronary-subclavian steal syndrome following coronary artery bypass grafting.

Angina pectoris resulting from the coronary-subclavian steal syndrome is a rare phenomenon with only 10 previously reported cases. However, with the increasing use of the internal mammary artery in the coronary artery bypass graft (CABG) procedure it may be encountered more frequently in the future. We report our recent experience with coronary-subclavian steal syndrome after CABG with 2 patients in whom complete relief from angina pectoris was obtained following bypass of a proximal subclavian artery occlusion in one patient and improvement of angina in the other. A review of the relevant literature is also presented.

Arteriovenous malformation of the tongue.

Polyvinyl alcohol particles used to embolize an arteriovenous malformation of the tongue were only temporarily successful. Additional embolization therapy was necessary and was complicated by ischemic ulcers of the tongue. We conclude that embolization therapy can be used, but the efficacy of this therapy in the longer term remains to be determined.

Renal revascularization in anuric patients: determinants of outcome.

We describe three patients who recently had surgical revascularization for prolonged anuria due to renal artery occlusion. A review of the literature revealed 31 similar patients with sufficient data to allow comparison. There was no correlation between the interval of anuria and the surgical outcome regarding survival, renal function, and blood pressure. On renal angiography, 16 patients had nephrogram as evidence of collateral circulation. Seven patients had no renal perfusion. There was no significant difference in renal function, blood pressure, or survival after renal reperfusion in patients with or without nephrogram. In patients who received vascular grafts, the postoperative serum creatinine level and blood pressure were significantly lower than those of patients who had thromboendarterectomy (P less than .05). In contradistinction to commonly held concepts, these findings are independent of collateral circulation.

Coumarin necrosis--a review of the literature.

Skin and soft tissue necrosis is a rare complication of anticoagulation therapy. Two patients who exhibited the spectrum of this disorder are described. The clinical features, etiology, pathophysiology, and treatment of coumarin skin necrosis are outlined, and the English-language literature is reviewed.

Complications of vascular access for hemodialysis.

This study of 533 vascular access sites for long-term hemodialysis in patients with end-stage renal disease, accumulating more than 12,000 patient months, indicated that primary arteriovenous fistula (AVF) is the procedure of choice. The group receiving primary AVF had the greatest duration of patency: 84% at three years compared to 70% for the group receiving polytetrafluoroethylene (PTFE) grafts and less than 50% for those receiving bovine carotid artery heterografts (BCAH). Furthermore, the primary AVF group had fewer complications (25 complications in 273 fistulas) than either the BCAH group (61 in 58 grafts) or the PTFE group (171 in 202 grafts). No complication resulted in death in the primary AVF group, but seven deaths resulted from complications of the access in the graft groups, further solidifying the position of the primary AVF as the procedure of choice for chronic hemodialysis access.

Posttraumatic vertebral artery aneurysm and arteriovenous fistula: a case report.

A case of posttraumatic vertebral artery aneurysm and arteriovenous fistula in a 32-year-old man is presented. Embolization of the vertebral artery was accomplished with occluding spring emboli, producing entrapment of the vascular injury. A discussion of this treatment modality is presented.

Factors affecting the results of below knee amputation in patients with and without diabetes.

During a five year period, 113 below knee amputations were performed upon 100 patients. Multiple factors were examined for the effects on wound complication and reamputation rates. Healing without reamputation occurred in 91.9 per cent of those in the diabetic group and in 76.5 per cent of those in the nondiabetic group, p less than 0.05. Cellulitis of the foot did not significantly affect healing below the knee in patients with diabetes, 82.5 per cent with cellulitis versus 87.5 per cent without cellulitis, p greater than 0.05, but did affect healing in those in the nondiabetic group, 81.8 per cent success versus 66.7 per cent, p less than 0.05, and affected their minor wound complication rate, 50.0 per cent with cellulitis versus 26.5 per cent without cellulitis. Absence of femoral pulses uniformly predicted a nonhealing below the knee amputation in patients with cellulitis, whereas in patients without cellulitis, healing occurred in 85 per cent. Hemoglobin levels were inversely proportional to success rates only in patients with diabetes and cellulitis, 10.54 +/- 1.68 versus 12.85 +/- 2.30 grams per deciliter for failures, p = 0.016. Elevated white blood counts were predictive of failure to heal below the knee amputations only in those in the nondiabetic group without cellulitis, 10,110 +/- 3,200 cells per millimeter3 for success versus 13,750 +/- 3,300 cells per millimeter3 for failures, p = 0.018. Use of wound drains correlated with a 55.0 per cent wound complication rate versus 16.1 per cent when drains were not used. Wound complications were minimized when amputations were closed with subcuticular suture and skin tapes.

Perforation of the gallbladder due to blunt abdominal trauma.

Gallbladder perforation due to blunt trauma is an uncommon finding. We report our experience with six patients. The factors predisposing to perforation include a distended gallbladder because of either fasting or alcohol ingestion in normal patients, and obstruction of the cystic in patients with cholelithiasis. The diagnosis of gallbladder perforation after blunt injury may be suspected in patients with signs of an acute abdomen and hypotension that is not explained by blood loss. Peritoneal lavage that contains bile suggests the tentative diagnosis of trauma to the biliary tract or gallbladder, as well as to the liver or upper bowel. A cholecystectomy is the preferred treatment when gallbladder perforation occurs in the traumatized patient.

Traumatic colonic perforation. Review of 16 years' experience.

The surgical management of colon injuries in civilian practice requires individualization. Primary repair, either by debridement and suture or resection and anastomosis, is a safe method of management in selected cases and results in a shorter hospital stay, less morbidity and a complication rate that is no higher. In this series, over half of the colon injuries were managed in this way. Exteriorization and proximal colostomy are accepted methods of management, but possibly should be reserved for the more severely injured patient. The criteria for individualization are briefly summarized.

Arterial injuries of the legs associated with fractures and dislocations.

Twenty-nine patients with vascular injuries of the leg associated with fractures and dislocations were reviewed. The overall limb salvage rate was 69 percent and the amputation rate 31 percent. These rates are usually directly related to delay in diagnosis and treatment. Routine arteriography is recommended in all patients with the slightest signs of ischemia. Prompt diagnosis followed by prompt vascular repair and fracture fixation will result in greater limb salvage.

Pericardiodiaphragmatic hernia.

Twenty-seven reported cases of pericardial diaphragmatic hernia are reviewed and another case is added. This entity may be congenital or traumatic in origin, the latter being more frequent at a ratio of 2:1. All patients except one were male and the mean age at diagnosis was 40 years. The patients were usually symptomatic, the most frequent complaints being of cardiac or respiratory origin. Pneumoperitoneum may be diagnostic although chest roentgenograms and contrast studies may suggest the diagnosis. Computed axial tomography and echocardiography may prove useful in the future. We believe the anterior abdominal approach is preferable to the transthoracic approach in reducing the hernia and repairing the defect because it affords better exposure and easier accessibility to other intraabdominal disease and can easily be converted into a median sternotomy if needed. The stomach and transverse colon became herniated most frequently and in only three cases was a sac found. The defect involves the central leaflet of the diaphragm and primary repair generally results in a good prognosis.

Desmoid tumors of the abdominal wall.

Desmoid tumors are musculo-aponeurotic fibromatoses which most commonly occur in the abdominal wall. They do not metastasize but local recurrence is common. The treatment of choice is wide local excision of the mass and surrounding normal tissue. We have described a rare desmoid tumor which involved the abdominal wall as well as small and large bowel. En bloc intestinal resections were required for complete tumor extirpation.