Aorto-oesophageal fistula after corrosive ingestion: A case report.

BACKGROUND: Aorto-oesophageal fistula (AOF) are uncommon and exceedingly rare after corrosive ingestion. The authors report a case of AOF after corrosive ingestion that survived. A comprehensive literature review was performed to identify all cases of AOF after corrosive ingestion to determine the incidence of this condition, how it is best managed and what the outcomes are. CASE SUMMARY: A previously healthy 30-year-old male, presented with a corrosive oesophageal injury after drain cleaner ingestion. He did not require acute surgical resection, but developed long-segment oesophageal stricturing, which was initially managed with cautious dilatation and later stenting. An AOF was suspected at endoscopy performed two months after the ingestion, when the patient represented with massive upper gastrointestinal bleeding. The fistula was confirmed on computerised tomographic angiography. The initial bleeding at endoscopy was temporised by oesophageal stenting; a second stent was placed when bleeding recurred later the same day. The stenting successfully achieved temporary bleeding control, but resulted in sudden respiratory distress, which was found to be due to left main bronchus compression caused by the overlapping oesophageal stents. Definitive bleeding control was achieved by endovascular aortic stent-grafting. A retrosternal gastroplasty was subsequently performed to achieve gastrointestinal diversion to reduce the risk of stent-graft sepsis. He was subsequently successfully discharged and remains well one year post injury. CONCLUSION: AOF after corrosive ingestion is exceedingly rare, with a very high mortality. Most occur weeks to months after the initial corrosive ingestion. Conservative management is ill-advised.

Demographic, clinical, and anthropometric profiles and postoperative outcomes in patients with chronic limb threatening ischemia: A prospective descriptive study.

BACKGROUND: Chronic limb-threatening ischemia (CLTI) is a complex disease caused by peripheral artery disease. It is associated with ischemic foot pain (rest pain) and tissue loss in the form of chronic nonhealing foot ulcers or gangrene. CLTI has a high short-term risk of limb amputations, postoperative sepsis, and cardiovascular-related events. AIMS: The present study was conducted to assess the demographic and anthropometric profile of patients with CLTI and their postoperative outcomes after 2-year follow-up at Groote Schuur Hospital, Cape Town, South Africa. METHODS: This prospective descriptive pilot study, nested in a prospective cohort study, included adult patients with CLTI admitted to Groote Schuur Hospital from 1st January 2015 to 31st December 2016. Demographic data, anthropometric markers of CLTI, and the postoperative outcomes were documented using piloted and pretested vascular questionnaire. Descriptive statistics were used for baseline data, and postoperative outcomes were presented using actuarial life-table method (Kaplan-Meier analysis). Odds ratio, 95% confidence interval, and P value < 0.05 were used to test the hypothesis. RESULTS: Thirty-seven (50.6%) patients had a BMI >25.0. The mean waist: hip ratio was 0.96. Prevalence of smoking was 86%. Limb salvage and ambulation at 1 year were 79% and 67%, respectively. Majority of the patients who were ambulant preoperatively remained ambulant postoperatively. CONCLUSION: Most patients had truncal obesity with a high prevalence of smoking. High postoperative ambulatory recovery among ambulant preoperative patients was a significant outcome observed in our study.

Predictors of post-operative outcomes in patients with peripheral arterial disease and critical limb ischaemia: a systematic review and meta-analysis.

Background: A very small proportion (1%) of patients with peripheral artery disease (PAD) present with critical limb threatening ischaemia (CLTI) with poor prognosis. The present review showcased several pre-operative predictors and key post-operative outcomes. Identification of any modifiable predictors may impact positively on surgical outcomes. Design: PubMed/Medline, Google scholar and Cochrane databases were searched using terms such as "peripheral arterial disease" AND "critical limb ischemia," "post-operative outcome," AND "predictors of post-operative outcomes". Search was for relevant English-language articles published between January 1997 and December 2007 Selected articles were screened first by title and abstract, and selection of full articles was based on relevance using our inclusion and exclusion criteria and quality ratings performed with the MINORS score. Results: The included studies were published between 1997 and 2007. Only six (6) articles out of a total of 2,114 were deemed suitable for analysis. Ambulatory recovery was >70% at six months, 86.7% and 70.0% at one year and five years respectively. Rate of local wound complications was between 12% and 24%. Reported limb salvage rates were >90% at six months, >70% at one year and 70.0-90.0% at five years. Primary graft patency rate at one year ranged from 63% and 76.6%. Gangrene, diabetes and impaired pre-operative ambulatory function are associated with more wound complications, low limb salvage, reduced graft patency and poor functional outcome. Conclusion: Pre-operative ambulatory status was the most important predictor of post-operative ambulatory recovery. Diabetes mellitus was an important risk factor for prolonged wound healing, local wound complications and major amputation. Funding: None declared.

Penetrating femoral artery injuries: an urban trauma centre experience.

AIM: This study reviews a single centre experience with penetrating femoral artery injuries. PATIENTS AND METHODS: The records of all patients with femoral artery injuries admitted to the Trauma Centre at Groote Schuur Hospital from January 2002 to December 2012 were reviewed. These were analysed for demographics, injury mechanism, perioperative, and surgical management. Outcome was categorised by limb salvage. RESULTS: One-hundred and fifty-eight (158) patients with femoral artery injuries were identified. There were 144 (91%) men and 14 women with a mean age of 28 years. Ninety-five percent (N = 150) sustained penetrating injuries. The superficial femoral artery (87%) was most commonly injured. The most common type of arterial injury was a laceration (39%) and transection (37%). Eighty-one (51%) patients had a primary repair, 53 (33%) patients had a vein interposition graft, and 16 patients (10%) had a prosthetic graft. There were 78 (51%) concomitant venous injuries, 11 were repaired, and 1 vein patch repair was performed (15.4%). There were 4 (2.5%) primary amputations and 10 (6.5%) secondary amputations. There were no deaths. Statistically significant risk factors for secondary amputation derived by univariate analysis were: ischaemia (p < 0.0001), neurological deficit due to ischemia (p < 0.001), temporary vascular shunting (p < 0.001), and the absence of a palpable pulse post-repair (p < 0.01). CONCLUSION: This study has a primary and secondary amputation rate of 2.5 and 6.5%, respectively. There was greater than 90% limb salvage rate. The outcome of threatened limbs due to femoral artery injury is good, provided that there is no delay to surgery.

Upper limb ischaemia: a South African single-centre experience.

OBJECTIVE: The aims of this study were to report on our experience with upper limb ischaemia (ULI), to define the pattern and distribution of disease, describe key demographic features and report on conventional clinical outcomes. METHODS: This was a single-centre, retrospective, descriptive study. All patients (n = 64) who underwent a surgical intervention for ULI over a 12-year study period were included. Findings were analysed and compared with the current literature. RESULTS: A male:female ratio of 0.60 was reported. Two major subgroups of patients were identified. The patients in the thrombo-embolic subgroup (n = 30) were notably younger than expected (mean age 55 years) compared to those in the atherosclerotic occlusive disease subgroup (n = 12, mean age 57 years). Presentation overall was generally late, with 8.6% of acute ULI and 48.3% of chronic ULI patients presenting with irreversible ischaemia and tissue loss, respectively. Thrombo-embolism was the dominant vascular pathology reported in this case series (47%). Ninety-five procedures were performed in 64 patients (89 open, six endovascular). Peri-operative (30-day) mortality rate was 7.8%. Systemic and procedure-related complications were observed in 13 and 23%, respectively. The overall major amputation rate was 10.9%. Adherence to follow up was poor (51% at six months). CONCLUSION: Although few firm conclusions could be drawn, this review has expanded our overall perspective of ULI, specific to the population we serve. Collaboration between African vascular units should be encouraged in an attempt to further define the pattern of ULI by identifying distinct geographical confounders.

Prioritization of treatments for lower extremity peripheral artery disease in low- and middle-income countries.

INTRODUCTION: Lower extremity peripheral artery disease (PAD) is increasing in prevalence in low- and middle-income countries creating a large health care burden. Clinical management may require substantial resources but little consideration has been given to which treatments are appropriate for less advantaged countries. EVIDENCE ACQUISITION: The aim of this review was to systematically appraise published data on the costs and effectiveness of PAD treatments used commonly in high-income countries, and for an international consensus panel to review that information and propose a hierarchy of treatments relevant to low- and middle-income countries. EVIDENCE SYNTHESIS: Pharmacotherapy for intermittent claudication was found to be expensive and improve walking distance by a modest amount. Exercise and endovascular therapies were more effective and exercise the most cost-effective. For critical limb ischemia, bypass surgery and endovascular therapy, which are both resource intensive, resulted in similar rates of amputation-free survival. Substantial reductions in cardiovascular events occurred with use of low cost drugs (statins, ACE inhibitors, anti-platelets) and smoking cessation. CONCLUSIONS: The panel concluded that, in low- and middle-income countries, cardiovascular prevention is a top priority, whereas a lower priority should be given to pharmacotherapy for leg symptoms and revascularisation, except in countries with established vascular units.

Hand preference is selectively related to common and internal carotid arterial asymmetry.

This study documents relationships between handedness and carotid arterial asymmetries. The article is divided into two sections, considering first geometric (n = 195) and then haemodynamic (n = 228) asymmetries. In the geometric study, diameters, lengths, and angles of the common carotid arteries in left and right-handed participants were measured using computed tomography angiography scans. Resistance to blood flow was calculated according to Poiseuille's formula. In the haemodynamic study, peak systolic and end-diastolic velocity, vessel diameter, and volume flow rate of the common, internal, and external carotid arteries were measured in left and right-handed participants, using Doppler ultrasonography. The findings reveal for the first time that the extracranial arteries supplying the cerebral hemispheres are asymmetrical in a direction that increases blood flow to the hemisphere dominant for handedness. Significant handedness interactions were identified in arterial length, diameter, resistance to blood flow, velocity and flow volume rate (p < .001). Arterial resistance and volume flow rates significantly predicted hand preference and proficiency. Our findings reveal a vascular correlate of handedness, but causality cannot be determined from this study alone. These asymmetries appear to be independent of aortic arch anomalies, suggesting a top-down, possibly demand-driven, pattern of development.

Intimomedial mucoid degeneration causing aortic and renal artery aneurysms in a young adult.

Intimomedial mucoid degeneration (IMMD) is characterised by aneurysm formation following mucin deposition in the intima and media, with elastic tissue degeneration of the arterial wall. We present a case of a young adult who developed a diffusely aneurysmal aorta and its major branches, which was histopathologically confirmed as intimomedial mucoid degeneration, and a review of the literature. This case report attempts to raise the awareness of the reader to this rare cause of aortic aneurysm and to the bleeding diathesis associated with IMMD that may complicate surgery.

Tuberculous iliac artery aneurysm in a pediatric patient.

Vascular complications of tuberculous infections are rare and occur even less frequently in the pediatric population. Tuberculous pseudoaneurysms can occur either as a result of contiguous spread from a neighboring focus-invariably infected lymph nodes-or by hematogenous spread and seeding of acid-fast bacilli that lodge in the adventitia or media via the vasa vasorum. We report a case of turberculous right common iliac artery pseudoaneurysm in a 12-year-old and review the relevant literature.

Civilian popliteal artery injuries.

BACKGROUND: Civilian popliteal artery injuries are associated with significant amputation rates. AIM: The aim of this study was to identify factors associated with limb loss in patients with popliteal artery injuries. PATIENTS AND METHODS: We performed a retrospective chart review of prospectively collected data on patients with popliteal artery injuries presenting to the Trauma Centre at Groote Schuur Hospital, Cape Town, from 1 January 1999 to 31 December 2008. Demographic data, mechanism of injury, haemodynamic status, limb viability, special investigations, associated injuries, ischaemic time, surgical treatment and amputation rates were analysed. RESULTS: One hundred and thirty-six patients with popliteal artery injuries were identified. Penetrating and blunt trauma accounted for 81 (59.6%) and 55 (40.4%) injuries, respectively. Associated injuries included fractures in 66 patients (48.6%), knee dislocations in 29 (21.3%) and popliteal vein injuries in 59 (43.4%). Fifty-seven patients (41.9%) presented with a compartment syndrome. Arterial injuries were treated with reversed vein grafting in 68 patients, primary anastomosis in 33, prosthetic graft insertion in 11, and primary amputation in 7. Thirty-two patients underwent delayed amputation, giving an overall amputation rate of 37.5%. A delay of more than 7 hours of ischaemic time between injury and definitive repair (p=0.0236) and the presence of a compartment syndrome (p=0.003) were significantly associated with an increased amputation rate. CONCLUSION: The most significant factors associated with the high amputation rate of 37.5% were an ischaemic time longer than 7 hours, and the presence of a compartment syndrome.