Chylous pleural effusion associated with primary lymphedema and lymphangioma-like malformations.

We describe a patient with a chylous pleural effusion associated with primary lymphedema of his right leg and abdominal wall. On evaluation a generalized, severe hypoplasia of the lymphatic system turned out to be associated with hyperplastic, lymphangioma-like malformations.

Treatment of solitary arteriovenous fistulas.

Four patients with a solitary arteriovenous fistula were treated by transvascular balloon embolization technique, which resulted in complete fistula closure in three patients and partial closure in one. There were two vertebral arteriovenous fistulas, one peroneal arteriovenous fistula, and one radial arteriovenous fistula. The first two fistulas were spontaneous, the other two were traumatic. The only partial occlusion of the peroneal fistula was, in our opinion, due to a technical failure, the balloon was inflated slightly proximal to the fistular orificium instead of in the orificium itself. There were no complications, and there was no morbidity. In our opinion transvascular balloon embolization technique is the treatment of choice for solitary arteriovenous fistulas.

Leiomyosarcoma of large and small veins: clinical findings and results of treatment in six patients.

Vascular leiomyosarcomas are rare malignant tumours originating from the media of the vessel wall. Six patients (five women and one man, aged 44-66 years) have been treated for a vascular leiomyosarcoma located in the inferior vena cava (three patients), the suprarenal, the external iliac and an antecubital vein. In four patients, the tumour was large and extended beyond the vessel wall giving rise to a retroperitoneal mass. In two patients the tumour was confined to the inner wall of respectively a large and small vein, occluding the lumen; the former was in the inferior vena cava and the latter in an antecubital vein. Block resection was performed in all patients. The tumours showed mitotic indices ranging from 6-32 mitoses/10 high power fields. The five patients with retroperitoneal tumours received additional radiotherapy varying from 50.00-70.00 Gy, on the basis of either macroscopic residual tumour or indefinite radicality. One of these five patients developed distant metastases within 2.5 years without local recurrence, the other four had no evidence of recurrence at follow-up, 3-7 years (mean 4.2 years) after surgery. The results illustrate the role of adjuvant radiotherapy in the control of local recurrence, when resection in this type of tumour proves to be either non-radical or totally radical.

The combined treatment of congenital vascular defects.

UNLABELLED: Eighty-one patients with a vascular malformation on the extremities were evaluated. In 32 patients the abnormality was localised in the upper and in 49 in the lower extremity. Signs, symptoms, treatment modalities and long-term results were tabulated. In the upper extremity pain was the most frequent presenting symptom. Three types of malformation were distinguished: purely venous, venous with microshunts and malformations with macroshunts. The treatment of the first group consisted of excision of varices and superficial naevi, in the second group the combined treatment of embolisation and excision was the treatment of choice, in the last group the selective embolisation without resection was most frequently done. The treatment was most successful in those cases, where there was a malformation with macrofistulas in the shoulder-region or only a localised lesion, that could be excised. The first sign and symptom of the lower extremity was swelling or a naevus vasculosus. After inventarisation 4 groups of vascular malformations have been distinguished, the cavernous (venous), the cavernous (venous) with microshunts, the arteriovenous with macrofistulas and a purely venous (truncular) group, which we did not have in our patients with an upper extremity abnormality. Conservative treatment in purely venous malformations prevented progression, the combined treatment was successful in patients with an AV-malformation of the pelvis, or around the knee or in patients with a small excisable lesion. IN CONCLUSION: the purely venous abnormality can be successfully treated with conservative measures, the arteriovenous malformation with macroshunts in pelvis and shoulder region should be embolised, and circumscript lesions excised with or without embolisation, depending on the character of the lesion.

Percutaneous intentional extraluminal recanalisation of the femoropopliteal artery.

Percutaneous intentional extraluminal recanalisation (PIER) of the femoropopliteal artery is a new catheter technique to overcome long chronic occlusions. This technique was applied to 40 long chronic occlusions of the femoropopliteal segment. The mean length of the superficial femoral artery (SEA) occlusions was 16.9 cm, the mean length of the popliteal occlusions was 11.8 cm and the mean length of the femoropopliteal occlusions was 27.6 cm. Primary recanalisation success was 85%. Patency showed a significant correlation with poor initial angiographic result (p < 0.05). Life-time table analysis of the successful group demonstrated a primary clinical patency of 59% at 1 and 2 years and a secondary clinical patency of 71% at 1 year and 65% at 2 years. There were no serious complications related to this technique. PIER technique is simple and cost-effective, and shows a good initial success-rate with a promising 2 years clinical patency. This technique might be of importance for patients with a critical lower leg ischaemia, when there are contraindications for primary bypass surgery either from a technical or a general point of view.

An unusual cause of an inferior vena cava syndrome.

Two patients are presented with an occlusion of the infrarenal vena cava caused by a vena cava aneurysm. This rare congenital vena caval anomaly may mimic retroperitoneal lymphadenopathy, especially on CT- imaging without contrast enhancement.

Catheter for percutaneous thrombectomy: first clinical experience.

The authors evaluated a double-lumen thrombectomy catheter that functions by way of the Venturi effect in seven consecutive patients with thrombus in the superficial femoral artery. The estimated age of the thrombotic material was between 3 days and 9 weeks. Thrombectomy was successful in all patients, and mean time required was less than 20 minutes. In five patients, diagnosis, thrombectomy, and therapeutic intervention were successfully performed in one session.

Diagnosis of arterial disease of the lower extremities with duplex ultrasonography.

The development of duplex scanning carries the prospect of an entire non-invasive work-up of patients with peripheral arterial occlusive disease. To obtain the best available estimates of its diagnostic accuracy, a meta-analysis of 71 studies evaluating duplex scanning was performed. Independent methodological judgement left 16 studies for data extraction. Pooled estimates (95 per cent confidence interval of sensitivity and specificity for detection of a stenosis greater than or equal to 50 per cent or occlusion in the aortoiliac tract were 86 (80-91) per cent and 97 (95-99) per cent respectively. The results for the femoropopliteal tract compared well with this, with a sensitivity of 80 (74-85) per cent and a specificity of 96 (94-98) per cent. The accuracy of detection of a stenosis greater than or equal to 50 per cent or an occlusion in the infragenicular arteries was lower with a sensitivity and specificity of 83 (59-96) per cent and 84 (69-93) per cent respectively. Duplex scanning is an accurate tool for assessment of atherosclerotic lesions in the aortoiliac and femoropopliteal tract and can replace routine preinterventional angiography in a substantial number of patients.

Arterial thrombosis below the inguinal ligament: percutaneous treatment with a thrombosuction catheter.

PURPOSE: To assess the safety and clinical efficacy of using a thrombosuction catheter for treatment of arterial thrombosis below the inguinal ligament. MATERIALS AND METHODS: The catheter was used in a consecutive group of 28 patients (10 women, 18 men; age range, 38-87 years; mean age, 66.7 years; with 11 native vessels and 17 grafts) with acute infrainguinal thrombosis. Initial local success, clinical success, and 30-day outcome were studied. RESULTS: The initial local success rate was 82%. The clinical success rate was 73% for native vessels and 53% for grafts. The 30-day success rate was 73% for native vessels and 35% for grafts. Displacement of thrombotic material during the procedure resulted in a clinical complication in one patient. There were no bleeding complications. In 58% of all patients (n = 26), no lytic drug was used. CONCLUSION: The thrombosuction catheter seems to be a safe, fast-acting alternative or supplement to local lysis therapy for infrainguinal arterial thrombosis.

Improved monitoring of myocardial ischaemia during major vascular surgery using transoesophageal echocardiography.

As regional wall motion abnormality (RWA) is the first sign of ischaemia, transoesophageal echocardiography was evaluated as a monitoring device in 51 patients undergoing abdominal aortic surgery. Wall motion of the entire left ventricular wall (nine segments) was semiquantitatively evaluated 15 min before and after aortic cross-clamping and 3 h after declamping. In addition, limb lead II of the electrocardiogram was simultaneously recorded. At baseline, RWA was present in 16 patients (31%). New or worsened RWA 15 min after aortic cross-clamping was seen in 17 patients, of whom 11 had persistent RWA, i.e. it was still present 3 h after declamping. This was associated in seven patients with enzymatically documented myocardial infarction. Only one infarct patient demonstrated ST segment changes of more than 1 mm. Thus, a single electrocardiographic surface lead is insensitive for perioperative myocardial ischaemia detection. Furthermore, new and/or worsened RWA after aortic cross-clamping, which persists until 3 h after declamping, is, to a considerable degree, associated with perioperative infarction.

Surgical approaches for unresectable primary carcinoma of the hepatic hilus.

Thirteen patients with proximal malignant obstruction of the biliary tract secondary to primary cholangiocarcinoma are presented. Seven of these patients had bilateral involvement of the major vessels of the porta hepatis, and 12 had bilateral involvement of the main hepatic ducts up to the level of segmental bifurcation. Resection of the tumor was carried out in all of the patients. Extensive resection of the liver with resection of the regional vascular structures was done in six. Another six underwent resection of the liver without resection of the regional vascular structures. The remaining patient underwent resection of the tumor and of the regional revascular structures alone. Vascular resection included resection and reconstruction of both the portal vein and hepatic artery in four patients or only of the portal vein in three. Biliary drainage was carried out by intrahepatic cholangiojejunostomies between segmental hepatic ducts and a Roux-en-Y loop. Two patients died and ten are alive. The quality of postoperative life is satisfactory and the patients are free of sequelae and symptoms secondary to operation or disease. This approach is recommended for the management of a number of patients with bilateral vascular or biliary involvement secondary to primary cholangiocarcinoma of the porta hepatis. For those patients, this approach offers a promising alternative.

Morphology and function of preserved microvascular arterial grafts: an experimental study in rats.

The aim of this study is to examine the morphology and function and small-caliber, arterial grafts after preservation in the University of Wisconsin solution (UW). Rat carotid arteries were stored in UW (n = 10) or in phosphate-buffered saline (PBS) (n = 10) for 1, 3, 7, and 14 days and were examined with light microscopy (LM) and scanning electron microscopy (SEM). Rat aortic preparations were stored in UW or PBS for 1 hour, 24 hours, 72 hours, 7 days, and 14 days and assessed for functional responses (stimulated contraction and endothelium-dependent relaxation). Segments (5 mm) of rat carotid arteries were stored in UW or PBS for 3 days, 7 days, and 14 days and orthotopically implanted as autografts and allografts. No immunosuppressive or anticoagulant agents were used. After 28 days of implantation, the grafts were assessed for patency and excised for LM and SEM. In UW, the endothelial layer remained intact up to 9 days of storage. In PBS, the endothelial layer showed deterioration after 1 day and was completely lost after 3 days. Functional responses were demonstrated to exist for as long as 7 days storage in UW. In PBS, no responses could be evoked after 24 hours storage. Autografts preserved in UW for 3 days (n = 6), 7 days (n = 6), and 14 days (n = 6) showed patency rates of 83.3%, 66.6%, and 66.6%, respectively, whereas patency rates of allografts were 66.6%, 33.3%, and 33.3%, respectively. Autografts stored in PBS for 3 days (n = 6), 7 days (n = 6), and 14 days (n = 6) showed patency rates of 33.3%, 33.3%, and 50%, respectively, whereas patency rates of allografts were 16.7%, 0%, and 33.3%, respectively. The UW preserved autografts showed normal morphology. All other groups showed vessel wall degeneration which in the allograft groups, were accompanied by lymphocellular infiltration. In conclusion, the endothelial layer and vessel wall of arteries are adequately preserved in UW. Functional responses are retained up to 14 days storage in UW, but, are lost after 24 hours storage in PBS. Autograft implantation studies accordingly show good performance of arterial segments preserved in UW, whereas allografts are subject to degradation as a result of rejection.

Morphology and function of dog arterial grafts preserved in UW-solution.

OBJECTIVES: To assess the function of arterial grafts after prolonged preservation in the University of Wisconsin solution (UW), in vitro and in vivo. METHODS: Carotid arteries were harvested from dogs and stored for 1-21 days at 4 degrees C in UW (n = 10) or in PBS (0.9% NaCl, pH 7.4), (PBS) (n = 10). Slices were examined by lightmicroscopy (LM) and scanning electron microscopy (SEM). For viability testing, specimens were connected to an isometric force transducer (2 x n = 9). Contractile and relaxation responses were examined by adding phenylephrine (200 microM) and metacholine (200 microM), respectively. For in vivo studies (n = 41), 2.5cm carotid artery segments were implanted or orthotopically, as autografts and allografts, after 14 days of storage in UW or in PBS. Autologous veins were used as controls. After 28 days or 56 days, arteriography was performed and the grafts were excised for LM and SEM. RESULTS: The arterial endothelial layer remained intact after up to 14 days of storage in UW. In PBS, the endothelium was lost after 3 days. The functional response after 14 days storage in UW was approximately 50% vs. 0% after 14 days in PBS. In the autografts, total patencies (28 days + 56 days) were 100% (8/8) and 63% (5/8) for UW and PBS stored grafts, respectively. In the allografts, the UW and PBS preserved grafts showed total patencies of 86% (12/14) and 83% (5/6), respectively. Microscopically, the allografts showed fibrotic degeneration. CONCLUSIONS: Arteries are well preserved in UW up to 14 days of storage. Arterial autografts preserved in UW showed good patency and better integrity of the vessel wall after implantation, than grafts stored in PBS or allografts (without immunosuppressive therapy).