Infected Viabahn stent graft in the superficial femoral artery.

We present a case of an infected stent graft in the superficial femoral artery (SFA). A 67-year-old woman underwent excision of an infected Viabahn stent graft. At exploration there was no apparent artery around the majority of the stent graft, suggesting that the SFA had been autolysed. Infected stents and stent grafts are rare in the SFA position. The risk of infection is likely minimised with standard treatments including drainage of infection prior to stent graft placement and periprocedural antibiotic administration. Successful management will, in most cases, require excision of the stent graft and adjunctive arterial reconstruction, as necessary.

Management and outcomes of hepatic cirrhosis: Findings from the RING study.

BACKGROUND/AIM: Hepatic cirrhosis is a frequent reason for ordinary hospital admission (OA). The RING study collected hospital discharge files (HDF) from Italian hospital gastroenterology units (IGU). This caselist provides a broad picture of the patients admitted for this pathology. MATERIAL/METHODS: More than 50,000 HDF for OA were collected between 2001 and 2004 from 26 IGU. RESULTS: Eight thousand four hundred and eighty-seven HDF (16%) had a diagnosis of hepatic cirrhosis; Child-Pugh classes were 20.2% A, 34.8% B and 45.0% C. Patients' mean age was 63.7+/-12.1 years and 62.5% were male. A 61.1% of the cirrhosis cases had ascites, 29.9% portal-systemic encephalopathy, 29.2% hepatocellular carcinoma (HCC), 10% bleeding varices, 3.0% hepatorenal syndrome (HRS). Mortality for OA for cirrhosis was 5.7% versus 2.6% for other diagnoses. The proportion varied with the severity of the cirrhosis: 0% for Child A, 1.1% B, 10.5% C. Mortality was significantly associated with: Child-Pugh at admission (odds ratio: OR 9.2), HRS (OR 11.7), bleeding varices (OR 2.2), HCC (OR 1.8). CONCLUSIONS: Hepatic cirrhosis was found in 16% of the OA to IGU and mortality was double the rate for all the other pathologies in the same wards. Child-Pugh is a useful prognostic tool, higher classes implying a greater risk of death. HRS and bleeding varices were the complications with most influence on in-hospital mortality.

Sequential femoral-tibial bypass for severe limb ischemia.

Sequential femoral-popliteal-tibial bypass has been recommended for surgical treatment of severe lower limb ischemia in patients with complex multisegmental arterial occlusion. To evaluate this alternative technique critically, sequential grafting was performed in 40 limbs with severe ischemia manifest by rest pain (20), nonhealing ulceration (eight), or gangrene (12). Measurement of segmental Doppler arterial pressure revealed a significant increase in ankle brachial index from 0.29 +/- 0.15 before operation to 0.93 +/- 0.12 after operation, confirming the hemodynamic improvement among these patients. In the early postoperative period occlusion of the distal graft segment was recognized in 12 patients by a characteristic reduction of the ankle/brachial index (0.50 +/- 0.14), while the low thigh pressures remained unchanged. Recurrent severe ischemia was prevented in most by persistent patency of the proximal graft segment. Overall, significant hemodynamic improvement was achieved in 29 of 38 limbs, a limb salvage rate (76%) comparable to that reported for femoral-distal bypass or femoral-popliteal bypass to an isolated popliteal segment. Early graft failure in this series resulted in major amputation in eight of 16 limbs, a significantly lower rate than for these other techniques. Sequential bypass grafting is a useful alternative method for limb salvage. The preservation of the proximal graft patency after distal segmental occlusion may be an important characteristic of this type of reconstruction.

Forefoot perfusion pressure and minor amputation for gangrene.

In many cases of digital gangrene, limited amputation to preserve the majority of the foot is possible. In the absence of invasive infection, forefoot perfusion pressure is the single most important factor in determining outcome of minor amputation. At ankle pressures of less than 35 mm. Hg, salvage of the foot appears to be futile. The presence or absence of diabetes mellitus has no noticeable effect on the result of amputation. Ankle systolic pressure measurement cannot supplant but should supplement clinical judgement in selecting surgical treatment for gangrene.

Lymphatic disruption in varicose vein surgery.

In order to investigate the possibility of lymphatic disruption occurring during varicose vein surgery, lymphangiography performed by a modification of the Kinmonth technique was done in seven patients before and after standard surgical ablation of primary varicose veins. All seven patients demonstrated marked disruption of lymphatics. Extravasation of lymphangiogram contrast medium at the calf level and at the thigh level precluded demonstration of the groin lymphatics. It is concluded that lymphatic disruption attends varicose vein removal and such lymphatic damage contributes to postoperative leg edema.

Early experience with in situ saphenous vein bypass for distal arterial reconstruction.

During a 36-month period 74 patients underwent infrainguinal in situ saphenous vein bypass to the popliteal or tibial vessels. The first 54 operations were performed with standard valvulotomes and valve-cutting scissors, while in the last 20 operations a new intraluminal valve-cutting device was used to incise the valves. Ninety-four percent of bypasses were performed for limb salvage, 80% of all operations were done to the tibial vessels, and 31% of bypasses were done to the ankle vessels. The operation was attempted in 81 patients and completed in 74 patients, for a vein utilization rate of 91%. Fifty-five percent of all veins had a distal diameter of less than 4 mm (average 3.6 mm). The patency rates were 92% at 3 months and 90% at 12 and 36 months for all grafts. There were six failed grafts, all within the first 6 months, and eight diabetic patients required reoperation, two for missed valve leaflets, and three needed revision of the distal anastomosis; however, all these grafts were patent at the time of reexploration. There were four perioperative deaths and two patients had nonfatal postoperative myocardial infarctions. This study demonstrates that in situ saphenous vein grafting provides for a high vein utilization rate and suggests that the technique provides for higher graft patency and limb salvage rates than do more traditional types of procedures.

Adductor canal compression syndrome.

Adductor canal syndrome is an unusual cause of acute arterial occlusion in younger men. It is the result of arterial compression by an abnormal musculotendinous band arising from the adductor magnus muscle and lying adjacent and superior to the adductor tendon. The pathogenetic mechanism of this syndrome resembles that of popliteal fossa entrapment and can become manifest after exercise. Since this syndrome occurs in younger men in whom acute arterial occlusion can lead to limb loss, recognition of the presence of apparent ischemic symptoms after exercise in an otherwise healthy young man is important. The treatment consists of the division of the abnormal band and restoration of arterial continuity by appropriate means. A search for bilateral lesions can help avoid future problems even when the symptoms are unilateral.

Ankle bypass: should we go the distance?

This report reviewed the results of 47 distal arterial reconstructions to or below the level of the malleolus. The operations were performed by the techniques of popliteal-to-distal bypass (20 procedures) and in situ bypass (27 procedures). Seventy-five percent of patients had gangrene of ischemic ulceration, and all procedures were performed for limb salvage. Seventy-three percent of all patients were diabetic. The patency rates for popliteal-to-distal bypass with reversed saphenous vein were 92 percent at 24 months and 57 percent at 60 months, with a limb salvage rate of 70 percent at 60 months; the patency rates for popliteal-to-distal bypass with PTFE were 53 percent at 12 months and 0 at 36 months, with a limb salvage rate of 53 percent at 36 months; and the patency rate for in situ saphenous vein bypass was 96 percent at 24 months, with a limb salvage rate of 80 percent at 24 months. Early results are promising for ankle bypass using the techniques of popliteal-to-distal and in situ bypass.

Factors affecting trace-metal bioaccumulation in Finnish headwater lakes.

Fourteen unpolluted Finnish headwater lakes with pH values varying from 4.8 to 7.0 were studied for trace-metal concentrations in water, sediment, aquatic plants (Nuphar luteum L., Sparganium sp.), aquatic insect larvae (Limnophilus sp., Phryganea sp.) and fish (Esox lucius L., Perca fluviatilis L., Coregonus sp., Salvelinus fontinalis L., Salmo trutta L.). Trace-metal deposition was estimated by analysing the snowpack. Non-parametric correlation analysis was carried out between trace metal concentrations in biota and pH, ANC, TOC, CA + Mg concentration in water and a given metal concentration in water and sediment. Bioaccumulation of several trace metals increased with increasing acidity and decreasing ANC in water. This was especially true for Pb and Cd. Aquatic plants were, in general, the best indicator group concerning differences in trace-metal bioaccumulation in lakes with different acidity. There was some evidence that a higher concentration of TOC in water may reduce bioaccumulation of Pb, Cd and Zn in aquatic plants and fish. The copper concentration in sediment was the only background variable explaining Cu concentration in aquatic insects. Multivariate analysis of the whole background data gave comparable preliminary results. Over 80% of the trace metal concentrations in biota of different lakes was explained by the background variables. In general, elevated concentrations of most of these trace metals can be expected to occur in the biota of acidified low calcareous lakes.

Concentrations of polychlorinated dibenzo-p-dioxins and furans in fish downstream from a Ky-5 manufacturing.

Concentrations of polychlorinated dibenzo-p-dioxins and dibenzofurans (PCDD/Fs) were studied in seven fish species, burbot (Lota lota), pike (Esox lucius), perch (Perca fluviatilis), pikeperch (Stizopedion lucioperca), bream (Abramis brama), salmon (Salmo salar) and Baltic herring (Clupea harengus membras) in River Kymijoki and its estuary polluted by Ky-5 manufacturing. The fish were caught at 14 localities along the river and its estuary. The selected species represent different trophic levels and/or inhabit different environments. The concentrations of PCDD/Fs were low, in most samples below 1 pg g(-1) ITEQ (NATO/CCMS 1988) fresh weight (fw) in muscle, except salmon and Baltic herring. These two species graze at the open sea and consequently accumulate contaminants at a large area in the Baltic Sea. The lipid content in salmon and Baltic herring was an order of magnitude higher than in other species. PCDD/Fs in fish muscle showed only slightly elevated levels in the Kymijoki area and its estuary as compared to the levels in the same species in Finnish freshwaters and sea areas. The concentration of the main impurities of the fungicide Ky-5 was higher in the Kymijoki River downstream the Ky-5 manufacturing place compared to the up-stream locations. The PCDD/F concentrations in fish liver and spawn were 10-100 times higher than the concentration in muscle, because of the much higher lipid concentrations of these organes. Consequently, the tolerable daily intake values could be as much as 100 times smaller (M. Korhonen, M. Verta, T. Vartiainen, Organohalog. Comp. 32 (1997) 305-310; P. Mikkelson, J. Paasivirta, H. Kiviranta, Organohalog. Comp. 39 (1998) 59-62).

Isolated hypogastric artery aneurysms.

Although isolated hypogastric artery aneurysms are among the rarest of all aortoiliac aneurysms, they are among the most devastating. Two cases, one with rupture directly into the urinary bladder, are presented and the typical clinical triad of compressive symptoms, pelvic mass, and previous aneurysm is described. Intraoperative management is predicated upon sac obliteration with minimal tissue dissection. An aggressive approach to asymptomatic or minimally symptomatic aneurysms is urged due to the very high mortality following rupture.

Mesoatrial shunting for portal decompression in alcoholic cirrhosis.

A 36-year-old Chinese man with alcoholic cirrhosis presented to hospital with exsanguinating variceal hemorrhage. Conventional porta-systemic decompressive operations could not be done because of dense vascular adhesions from two previous operations and a sub-hepatic abcess. A mesenteric-to-right-atrial shunt was done with successful control of hemorrhage and reduction of portal pressure. Long-term follow-up reveals no further bleeding and a return to full-time employment. We conclude that mesoatrial shunting is a useful alternative procedure for portasystemic decompression in alcoholic cirrhosis, although one which will be needed only in unusual circumstances.

Alternative imaging techniques in vascular surgery.

Progress in vascular surgery has led to the need for more sophisticated methods of imaging the vascular system. Although conventional contrast angiography is still the primary method of visualizing the vascular system, it has problems and limitations that occasionally render it unsafe or inadequate. When conventional angiography cannot provide the needed information, 3 newer imaging methods--3-dimensional (3-D) spiral computed tomographic scanning, computed tomographic angiography, and magnetic resonance angiography--are being used more widely to supplement or replace contrast angiography. The advantages, disadvantages, and clinical application of each method will be described. These methods have fundamentally changed the practice of vascular surgery and a thorough knowledge of them is essential.

Hazardous organic compounds in biogas plant end products--soil burden and risk to food safety.

The end products (digestate, solid fraction of the digestate, liquid fraction of the digestate) of ten biogas production lines in Finland were analyzed for ten hazardous organic compounds or compound groups: polychlorinated dibenzo-p-dioxins and furans (PCDD/Fs), polychlorinated biphenyls (PCB(7)), polyaromatic hydrocarbons (PAH(16)), bis-(2-ethylhexyl) phthalate (DEHP), perfluorinated alkyl compounds (PFCs), linear alkylbenzene sulfonates (LASs), nonylphenols and nonylphenol ethoxylates (NP+NPEOs), polybrominated diphenyl ethers (PBDEs), hexabromocyclododecane (HBCD) and tetrabromobisphenol A (TBBPA). Biogas plant feedstocks were divided into six groups: municipal sewage sludge, municipal biowaste, fat, food industry by-products, animal manure and others (consisting of milling by-products (husk) and raw former foodstuffs of animal origin from the retail trade). There was no clear connection between the origin of the feedstocks of a plant and the concentrations of hazardous organic compounds in the digestate. For PCDD/Fs and for DEHP, the median soil burden of the compound after a single addition of digestate was similar to the annual atmospheric deposition of the compound or compound group in Finland or other Nordic countries. For PFCs, the median soil burden was somewhat lower than the atmospheric deposition in Finland or Sweden. For NP+NPEOs, the soil burden was somewhat higher than the atmospheric deposition in Denmark. The median soil burden of PBDEs was 400 to 1000 times higher than the PBDE air deposition in Finland or in Sweden. With PBDEs, PFCs and HBCD, the impact of the use of end products should be a focus of further research. Highly persistent compounds, such as PBDE- and PFC-compounds may accumulate in agricultural soil after repeated use of organic fertilizers containing these compounds. For other compounds included in this study, agricultural use of biogas plant end products is unlikely to cause risk to food safety in Finland.

Time trends and congener profiles of PCDD/Fs, PCBs, and PBDEs in Baltic herring off the coast of Finland during 1978-2009.

In Finland, consumption of Baltic fatty fish may lead to high exposure to persistent organic pollutants (POPs), which might have hazardous health effects. Monitoring of POPs in Baltic fish enables the health authorities to keep dietary advice on fish consumption up to date. In this study, which is a compilation of analytical data from earlier studies, time trends and congener profiles of polychlorinated dioxins and furans (PCDD/Fs) and biphenyls (PCBs), and polybrominated diphenyl ethers (PBDEs) in Baltic herring are reported. Altogether 344 samples of Baltic herring from 1978-2009 were collected across the Finnish coast of the Baltic Sea. The chemical analysis was performed in an accredited testing laboratory with high resolution gas chromatography mass spectrometry. During the 31-year period, PCDD/F and PCB concentrations decreased on approximately 80%, from approximately 20 to 5 pg/g fw, expressed as WHO2005 TEQ. The PBDE concentrations experienced a 4-10 fold increase during late 1980s-early 1990s, and declined to 1978s levels of approximately 2 ng/g fw by 2009. The current concentrations of PCDD/Fs, PCBs and PBDEs in Baltic herring are relatively low, and mostly below EU maximum accepted levels, and are expected to continue decreasing. In the future, it may be possible to re-evaluate the consumption restrictions for this specific Baltic fatty fish.

Composite sequential bypasses to the ankle and beyond for limb salvage.

Composite grafts of polytetrafluoroethylene (PTFE) and saphenous vein were used for sequential bypasses to the ankle and foot in 35 men and 19 women (mean age 66.5 years). Presenting symptoms were rest pain (25), digital gangrene (19), and ischemic ulcer (10). Thirty-one tibial and 23 pedal bypasses were done and were followed up to 48 months (mean 26.4 months). The ankle pressure index rose from 0.31 +/- 0.11 preoperatively to 0.77 +/- 0.21 postoperatively. Mean graft flows were 34.8 ml/min. Composite sequential grafts took 51 minutes longer to perform than femoral-tibial vein grafts. Patency rates by the life-table method were 81.4% at 2 years and 72.4% at 4 years. Graft failures after the first 10 weeks usually led to amputation. Use of PTFE as an inflow conduit permits otherwise inadequate lengths of saphenous vein to be used for anastomosis to delicate distal vessels and takes advantage of the vein's ability to tolerate low flows. Our experience suggests that the excellent patency rates make sequential bypasses a reasonable option for limb salvage.