Vascular and Endovascular Surgery

The authors report a series of 10 patients who presented with 4 primary aorto-enteric fistulas (AEFs) and 8 secondary AEFs. Gastrointestinal bleeding is the main feature of this serious complication. The diagnosis is difficult; no single procedure: endoscopy, angiography, CAT scan, or upper gastrointestinal film series is regularly diagnostic for AEF. Acute massive exsanguination needs urgent explorative xyphopubic midline laparotomy without preoperative work- up. The surgical treatment consists of endoaneurysmorraphy or graft prosthesis resection without "in situ" vascular reconstruction. The extraanatomic bypass permits the revascularization of the lower limbs. In this series, the prognosis appeared to be poor. The mortality rate with primary AEF was 50%, and the morbidity consisted, after "in situ" reconstruction, of early or late secondary AEF. In secondary AEF, the mortality rate after extraanatomic reconstruction with graft excision was 62%. The main complications were infection, fistuliza tion, and hemorrhage.

Perioperative blood flow, blood flow velocity, arterial diameter, and venous diameter are factors with known influence in survival with arteriovenous fistu las (AVF).

Twenty-four femoral AVFs were constructed in 12 dogs. The fistulas were randomly divided, and in half of them the vein and the artery were mechani cally dilated (in an extension of 23 cm) with a Fogarty or Foley catheter.

After dilatation, perioperative blood flow, blood flow velocity, and arterial diameter were greater in the dilated group when compared to the nondilated group (p < 0.005, p < 0.005, p < 0.025 respectively). In the dogs reoperated at day 30, similar results were observed and also venous diameter was greater in the dilated fistulas (p < 0.05).

In conclusion, simple mechanical dilatation of a long venous and arterial segment improved most of the factors that have influence in AVF patency and improved the maturation of the AVF vein. We believe that it would be useful for the construction of arteriovenous fistulas in uremic patients.

Sixty-two patients with arterial trauma and fractures or dislocations are re ported, half of the cases acute. The average age was 26.4 years, and 92% were males. Car accidents, blunt trauma, and bullets were the common injury agents. Thrombosis, pulsating hematoma, and complete transection were the main acute arterial lesions, and false aneurysms, chronic occlusions, and trau matic AV fistulas were the main chronic lesions. Fractures of the lower limb (64.5%) were more common than those of the upper limbs (25.8%), and hence, so were arterial lesions. Arterial reconstruction was made in every case, and venous repair was needed in 51.6% of cases. Reduction and casting was done in (51.6%) of cases, and internal fixation was needed in 40.3%. The amputation rate was 8.1%, and the mortality rate was 1.6%.

In an effort to establish the true incidence of cranial nerve dysfunction after carotid endarterectomy, 50 consecutive carotid endarterectomy procedures were assessed by careful and objective preoperative and postoperative cranial nerve evaluations, including indirect laryngoscopic examination by a trained ENT surgeon.

Of the 50 patients evaluated, 2 (4%) were found to have a postoperative cranial nerve deficit, and these were the following: 1 (2%) recurrent laryngeal, none (0%) superior laryngeal, 1 (2%) marginal mandibular nerve, and none (0%) hypoglossal nerve. In no instance was any patient who was asymptomatic found to have unsuspected objective evidence of cranial nerve injury; on the other hand, both symptomatic patients were found to have a significant cranial nerve injury by further evaluation.

Our objective data refute the literature that would support a magnitude of either symptomatic or asymptomatic cranial nerve injuries following such a procedure. Our study further fails to support a need for a more extensive exam ination that would routinely include indirect laryngoscopy and a specialist-ori ented consultation—both of which appear neither warranted nor cost effective.

Because of improvement of the leads, the use of dual-chamber pacing is increasing. Usually, two leads are required, and these are introduced through the cephalic vein. However, some physicians prefer puncture of the subclavian vein for insertion of leads. But two major complications have been reported with this technique: major air embolus and massive hemorrhage. The author describes a new apparatus designed to avoid these complications.

From 1970 to 1985, the authors performed 440 partial interruptions of the inferior vena cava for prophylaxis of embolisms. An extraluminal clip was im planted in 248 patients, an intraluminal filter in 138 patients, and an intra luminal umbrella in 54 patients.

Long-term clinical, phlebographic, and hemodynamic results are described. Situations indicating, and situations contraindicating, this prophylactic sur gical procedure are listed.

The extraluminal clip and the intraluminal filter were associated with less than 1% postoperative mortality, whereas a mortality rate of 7% was associated with the extraluminal umbrella. The permeability of the inferior vena cava and the hemodynamic status were not much compromised over a five- to fifteen-year period with the extraluminal clip or the intraluminal filter.

Investigation of the deep venous system of the lower limb must mainly aim to elucidate its capabilities. Because deep venous incompetence is necessarily con nected with a popliteal reflux accounted for by valvular incompetence of the popliteal vein, its presence must be clarified. An isolated valvular incompetence of the femoral vein without popliteal incompetence is of no clinical significance and should be disregarded. Only patients with popliteal reflux detected by Dop pler ultrasound require a further examination by venous pressure measure ments and by phlebography. An operation in the deep veins is admissible only when a popliteal reflux > 40%, and ambulatory venous pressure > 60 mmHg, a refilling time < 15 sec, a venous insufficiency > 20%, and a patency or recanalization of the deep venous > 70% have been confirmed. A correlation between venous pressure and Doppler recordings has been done.

One hundred eighteen patients (88 males, 30 females, mean age 67.2 years, age range 42 to 87 years) with successfully performed synthetic prosthetic by pass operations in the femoro-popliteal area were submitted in an open random ized study of two groups of 59 subjects to oral treatment by 400 mg pentoxifylline in special patented slow-release formulation or 500 mg ASA tid from two days before operation until twelve months after operation (with par enteral administration of both drugs on the day of surgery and two days after surgery). Effectiveness of prevention of reocclusion was assessed by patency rates and drug tolerability.

The examinations (clinical status, pulse palpation, Doppler-pressure mea surement, arteriography) were carried out before and on days five or six after operation, and also after three, six, nine, and twelve months of the follow-up period.

The life table analysis disclosed no significantly different patency rates (75% for the pentoxifylline-treated group and 74% for the ASA cohort).

A significantly superior tolerability was found in the patients treated with pentoxifylline, 6 patients (10%) reporting adverse reactions as compared with 33 (56%) in the ASA-treated group. The side effects consisted mostly of gastric upset, dizziness, and gastric hemorrhage. The medication was discontinued in 6 patients on pentoxifylline and 12 on ASA.

Reduced short-term mortality following thrombolytic treatment of acute myocardial infarction has been reported by earlier studies. This study was per formed to compare data from our institution with such results.

From January, 1984, through January, 1986, a total of 628 consecutive pa tients were admitted with acute myocardial infarction. Ninety-one patients (Group A) underwent intracoronary streptokinase (IC-SK) infusion to the in farct-related vessel with a total dose of 440,000 units. The average timing for this intervention from the onset of chest pain was 4.1 ±2.7 hours. Successful recanalization was achieved in 71 of 91 patients (78%). Patients seventy-five years of age or older were not offered IC-SK infusion. In this group, most candidates suitable for coronary angioplasty or bypass surgery had the proce dure within the same hospital admission. The remaining 537 patients (Group B) underwent conventional medical therapy during their hospitalization.

In-hospital mortality for Group A was reported in 4 of 91 patients (4.4%) versus 100 of 537 patients (18.6%) from Group B. These results seem to con form with earlier data that indicate a reduced short-term in-hospital mortality from acute myocardial infarction following IC-SK treatment. Besides recanali zation, this beneficial effect in Group A could also be attributed to earlier inter ventions by revascularization procedures in the majority of patients after recognition of the extent of their coronary artery disease.

We present a case of supravalvular aortic stenosis in an adult who had un dergone two previous attempts at repair, the second of which exacerbated his condition. We emphasize the technique used for repair of the anomaly and ia trogenic exacerbation in a patient who recovered well and is currently asympto matic.