Aortoenteric fistula treated with endovascular aortic stent-graft and bilateral chimney stent-grafts to renal arteries.

We report a patient with secondary aortoenteric fistula (AEF) presenting with a rectal bleeding. The patient had multiple comorbidities, precluding major open vascular surgery. We opted to perform a two-stage procedure, where an endovascular stent-graft was first deployed to exclude the AEF from the systemic circulation. As the AEF was at the proximal anastomosis of the previous Dacron graft and close to the renal artery ostia, chimney stent-grafts were placed in both renal arteries to maintain their patency. The second stage of the procedure involved a laparotomy to repair the defect in the duodenum to prevent further contamination from bowel contents.

Management of blunt traumatic thoracic aorta injuries with endovascular stent-grafts in a tertiary hospital in an urban Asian city.

BACKGROUND: Thoracic aortic injury from blunt trauma is a life-threatening condition with significant mortality and morbidity with open surgical repair. Endovascular means of treatment is emerging as an attractive and less invasive option. We report our experience with endovascular stent-graft repair for blunt traumatic thoracic aorta injury. METHODS: Between January 2003 and August 2009, six patients underwent endovascular repair of blunt traumatic thoracic aorta injury. Data from the medical records of these patients were analyzed. RESULTS: All patients had deceleration injury resulting in thoracic aorta pseudoaneurysm at the aortic isthmus just distal to the left subclavian artery. Four patients were motorcyclists who had been involved in road-traffic accidents and two had fallen from a height. The mean Injury Severity Score was 33.8 (range, 21-43). All procedures were performed within 48 hours of admission and technical success was 100%. Five patients (83.3%) had the left subclavian artery intentionally covered by the stent-graft to achieve adequate proximal landing zone. None of them had any left upper limb ischemic complications or cerebrovascular events after the procedure. One patient had preservation of the left subclavian artery because intraoperative vertebral angiogram showed a hypoplastic right vertebral artery. No other procedural complications, paraplegia, or deaths were reported. Mean follow-up was 18.8 months (range, 1.5-42 months). CONCLUSIONS: Our early experience of endovascular stent-grafting for blunt traumatic thoracic aorta injury suggests that this emerging technique is safe for treatment of such pathology in our inherently Asian population. Left subclavian artery may be sacrificed if adequate proximal landing zone is required for the stent-graft; and when vertebral angiogram was performed which did not show a dominant left vertebral artery.

Surgical management of infected pseudoaneurysms in intravenous drug abusers: single institution experience and a proposed algorithm.

BACKGROUND: Vascular complications from intravenous drug abuse pose significant challenges to vascular surgeons. No formalized policies have been reached on surgical management of the resultant infected pseudoaneurysm. METHODS: A retrospective review of all patients who underwent surgery for pseudoaneurysms due to chronic intravenous drug abuse from July 2005 to February 2008 was performed. RESULTS: A total of 15 patients with infected pseudoaneurysms from chronic intravenous drug abuse were operated on during the study period. The sites of involvement were restricted to the femoral (86.7%) and brachial (13.3%) areas. The drug involved was buprenorphine (Subutex) in all cases. Pain over the limb swelling (100%), pulsatility (60%), and symptoms suggestive of septicemia (46.7%) were the most common symptoms. Staphylococcus aureus was present in 93.3%. Diagnosis was achieved clinically in 26.7%, by duplex ultrasonography in 60.0%, and by computed tomography (CT) angiography in 13.3%. In the two patients with brachial pseudoaneurysms, the brachial artery was ligated in one, and a basilic vein patch was used in the other. In the 13 patients with femoral pseudoaneurysms, the pseudoaneurysm was ligated and excised in 8 (61.5%), and immediate reconstructive bypass surgery was performed in 5 (38.5%). Two patients had critical ischemia after ligation and required reconstructive bypass surgery a few weeks later. Postoperative complications included claudication, digital gangrene, localized wound infection, and rebleeding. There was no associated mortality. CONCLUSIONS: Pseudoaneurysm from intravenous drug abuse continues to pose significant challenges to surgeons worldwide, ranging from an accurate diagnosis to the choice of surgery. The aims of surgery must be to achieve adequate débridement and control infection and hemorrhage. Any associated postoperative complications must be identified and dealt with.

An unusual case of leiomyosarcoma of the inferior vena cava in a patient with a duplicated inferior vena cava.

Leiomyosarcoma of primary vascular origin is a rare primary soft tissue tumour, which arises mainly from the inferior vena cava (IVC). Clinical symptoms depend upon the size and location of the tumour and presents usually with abdominal pain, palpable mass and weight loss. Complete surgical resection with clear surgical margin plays a central therapeutic role. The effect of chemotherapy and radiation therapy remains to be evaluated. We report a 64 year old Chinese female who presented with abdominal mass and pain associated with weight loss and was subsequently diagnosed with inferior vena cava leiomyosarcoma. She underwent successful surgical resection but unfortunately developed recurrence of tumour 12 month post-operative. She was also found to have a duplicated inferior vena cave which allowed reconstitution of venous return from the lower limbs after surgical resection of the IVC tumour. We discuss the surgical treatment and results of leiomyosarcoma of the IVC.

Lap-band causing left gastric artery erosion presenting with torrential hemorrhage.

A 61-year-old lady presented 2 years after lap-band surgery with hemetemesis. She was stable on admission and band erosion was diagnosed on gastroscopy. Laparotomy was performed to remove the lap band. Upon division of the lap band, torrential hemorrhage from the eroded left gastric artery was encountered. An anterior gastrostomy was done to expose the artery. Intraoperative gastroscopy was also performed to define the cardioesophageal junction. The artery was ligated and the perforation and gastrostomy were repaired. The patient was discharged after 9 days in hospital. This case highlighted the potential injury to the left gastric artery in patients with band erosion presenting with hemetemesis. Torrential bleeding may be encountered upon division of the lap band, and this should be anticipated during laparotomy.

A case report of endovascular stenting in Salmonella mycotic aneurysm: a successful procedure in an immunocompromised patient.

INTRODUCTION: Mycotic aneurysms are associated with high mortality rates and are managed in the local setting with extra-anatomical bypass followed by ligation, exclusion and debridement of the aneurysm. This is the first case of successful endovascular stenting in an immunocompromised patient with Salmonella mycotic aneurysm. CLINICAL PICTURE: A middle-aged man who was HIV positive had Salmonella septicaemia. He developed abdominal pain 5 days after admission and a computed tomography (CT) scan of the abdomen revealed infrarenal aortitis. He developed a mycotic aneurysm 3 weeks later. TREATMENT: He opted for endovascular stenting and after prolonged antibiotic therapy and negative blood cultures, he underwent the procedure using a Talent stent, with an iliac extension. OUTCOME: He was discharged 1 week after stenting and maintained on oral bactrim based on sensitivity. At 1-year follow-up, he remains well symptomatically and CT scan showed no endoleak or collection. CONCLUSION: Endovascular stenting, though a fairly new procedure, can be successfully deployed even in a mycotic aneurysm in the right setting.

Complications relating to intravenous buprenorphine abuse: a single institution case series.

INTRODUCTION: We present a retrospective descriptive study of cases admitted to Tan Tock Seng Hospital from March 2005 to October 2005 with complications of Subutex abuse. CLINICAL PICTURE: A total of 8 patients were studied. Of the 8, 7 were male and one was female. Their complications consist of the following: arterial pseudoaneurysm (2), arterial pseudoaneurysm with infective venous thrombus (1), infective venous thrombus (1), venous thrombus (2), end arterial spasms (1) and sympathetic dystrophy (1). TREATMENT: For the patient who presented with buprenorphine-associated neuropathy, non-operative treatment with analgesics was given. Conservative medical therapy involving deep venous thrombosis treatment was instituted for the patient with deep venous thrombosis. Repair, restorative bypass and embolectomy surgery were performed for patients who had severe embolic/thrombotic complications. One of the patients who received the above surgery required amputation of his lower limb. OUTCOME: Of the 8 patients, 4 were treated medically, 3 required surgery and 1 required amputation. Their recoveries were uneventful. Of the 8, 1 absconded and was not followed up with. CONCLUSION: Parenteral injection of buprenorphine can cause a wide range of vascular complications from simple vascular irritation to severe infective thrombosis and pseudoaneurysms requiring limb amputations. Non-sterile preparation of an injected substance or non-sterile injection sites and the repeated punctures of major vessels are possible culprits in those who are seen to have acute infection of injection sites.

Utility of portable continuous-wave Doppler examination in screening for postoperative deep vein thrombosis.

BACKGROUND: Early and accurate diagnosis of post-surgical deep vein thrombosis (DVT) can be difficult and time-consuming, even with duplex ultrasonography. Portable continuous-wave Doppler ultrasonography may be useful in screening patients for postoperative DVT. Further confirmation of Doppler-positive cases by duplex ultrasound might then be more cost-effective. METHODS: All major post-surgical patients from the departments of general surgery, orthopaedic surgery and colorectal surgery were screened on the third postoperative day for DVT by assessing the quality of the flow signal ("whoosh") obtained by placing the probe over the femoral vein and subsequently over the popliteal vein, both with a distal squeeze, as well as assessment of phasic flow with respiration. An absent or attenuated "whoosh" was judged to be suspicious for DVT and required formal duplex ultrasonography. The first 800 consecutive patients were studied to determine the sensitivity, specificity and accuracy of portable Doppler ultrasonography for DVT screening. RESULTS: Twenty-four cases of DVT were diagnosed, comprising seven cases in the proximal veins and 17 cases in the calf veins. The sensitivity of Doppler ultrasonography was 12.5% and the specificity was 96.8%. The positive and negative predictive values were 10.7% and 97.3%, respectively. CONCLUSIONS: Portable Doppler ultrasonography does not have adequate accuracy to be used as a quick screening tool for DVT.

Intestinal schistosomiasis manifesting as colonic intussusception arising from a mucocele of the appendix: report of a case.

We report a case of intestinal schistosomiasis manifesting as colonic intussusception resulting from a mucocele of the appendix, caused by the obstruction of appendiceal outflow by schistosome egg-induced fibrosis. An 81-year-old woman from China presented with a tender right iliac fossa mass and computed tomography (CT) showed intussusception in the ascending colon. Exploratory laparotomy confirmed an appendiceal mass causing intussusception of the cecum into the ascending colon, with the appendix as the lead point, and lymphnode enlargement. We performed a right hemicolectomy for the appendiceal tumor. However, histologic examination revealed schistosoma eggs within the mucosa, submucosa, muscularis propria, and subserosal fat of the appendix, cecum, and ascending colon, and lymph nodes. The absence of dysplasia in the appendiceal mucosa indicated that the mucocele had developed from fibrosis induced by schistosome eggs obstructing the luminal outflow of mucin. Postoperatively, the patient was given praziquantel and recovered well.