Risk factors and management of patients with upper limb deep vein thrombosis.

STUDY OBJECTIVES: To determine the prevalence of endogenous and exogenous risk factors for venous thrombosis in patients with upper limb deep vein thrombosis (DVT), and to evaluate the risk of clinically detectable pulmonary embolus, recurrent DVT, and postphlebitic symptoms in these patients. DESIGN: A combined prospective and retrospective descriptive analysis of a cohort of patients with upper limb DVT compared with age- and sex-matched patients with lower limb DVT. SETTING: Internal medicine departments, and hematology and vascular surgery outpatient clinics at a tertiary-care university hospital. PATIENTS: Consecutive patients with "spontaneous" upper limb DVT diagnosed between 1989 and 1997 were studied. Twenty age- and sex-matched patients with lower limb DVT admitted to the hospital via the emergency department served as control patients. RESULTS: Eighteen patients with upper limb DVT were studied. An endogenous risk factor (thrombophilia) was present in 11 of 18 patients vs 8 of 20 control patients (p = not significant). In the upper limb group, nine patients had activated protein C resistance, four patients had anticardiolipin antibodies, and two patients had both forms of thrombophilia. Furthermore, 14 of the upper limb DVT patients were found to have an exogenous risk factor for thrombosis compared with 7 of the patients with lower limb DVT (p = 0.01), and 66.6% of patients with upper limb DVT had both an exogenous and an endogenous risk factor for thrombosis vs 15% of patients with lower limb DVT (p < 0.002). No clinically detectable pulmonary emboli occurred among the upper limb DVT patients. Three patients have minor postphlebitic symptoms. Two patients experienced recurrent DVT. CONCLUSION: In the majority of patients with upper limb DVT that we studied in this relatively small study, exogenous (environmental) or endogenous risk factors for venous thrombosis, or a combination of both, were found. Furthermore, in our patients, these thromboses had a low propensity to cause clinically significant pulmonary embolus and did not cause significant postphlebitic symptoms. Finally, we suggest that anticoagulant therapy for these thromboses may be adequate and that thrombolytic agents and surgical intervention are not routinely indicated.

Vascular surgical society of great britain and ireland: isolated femoral profundoplasty with endarterectomized superficial femoral artery for limb salvage in the elderly

BACKGROUND: This longitudinal observational study was designed to show that isolated profundoplasty to relieve a significant stenosis is a valid procedure for limb salvage in the elderly. METHODS: Twenty-seven patients with critical limb ischaemia underwent isolated profundoplasty using endarterectomized superficial femoral artery as an arterial patch. Nineteen patients were men. The mean age was 72 (range 65-79) years. All patients had rest pain with or without an ischaemic foot ulcer or pedal gangrene. RESULTS: There was no operative death or immediate operative failure. All 27 limbs were improved, with relief of rest pain, healing of ulcers and healing after minor foot amputations. The 27 patients underwent a mean of 30 (range 12-45) months of periodic observation in an outpatient clinic, either to the present time or until death. Two patients required late amputations and one a femorodistal bypass. CONCLUSION: Isolated profundoplasty has a place in leg revascularization in the high-risk elderly patient. Endarterectomized superficial femoral artery as a patch has the advantages of almost universal availability and anatomical convenience.

Bile composition and bile acid pool size. Comparison after truncal, selective, and highly selective vagotomy.

We studied biliary lipid composition and bile acid pool size in 29 patients surgically treated for duodenal ulcer. Fourteen were examined both before and after surgery, the rest postsurgically only. They were divided into three groups according to type of vagotomy. With duodenal fluid obtained via nasogastric tube, we determined bile acid pool size, bile concentrations, and lithogenic index. We found no significant differences in bile composition and bile acid pool size among the three types of vagotomy, postsurgically. However, patients studied before surgery, compared with the entire post-vagotomy group, had a significant increase in relative cholesterol content and lithogenic index, most pronounced in the truncal vagotomy group. Bile acid pool size was also increased postsurgically. Vagotomy may predispose to gallstone development by increasing the bile's relative cholesterol concentration and thus the lithogenic index. However, the slightly expanded bile acid pool size may improve cholesterol solubility in certain patients.

Isolated true atherosclerotic aneurysms of the deep femoral artery. Case report and literature review.

Isolated true atherosclerotic aneurysms of deep femoral artery are rare. We report on a case of an isolated (DFA) aneurysm of a large size. In reviewing the literature, the great latency of the disease, the high complication rate at presentation and the significant incidence concomitant aneurysms elsewhere are emphasized. Duplex scanning followed by angiography should be performed in order to establish the diagnosis, and to plan the operation. Twenty four cases have been reported so far. Elective surgical treatment is associated with little risk to the patient and avoids the need for emergent operations.

Traumatic scapulothoracic dissociation.

Scapulothoracic dissociation is an infrequent injury with a potentially devastating outcome. The diagnosis is based on clinical and radiographic findings of forequarter disruption. These include massive soft tissue swelling of the shoulder, displacement of the scapula and neurovascular injuries (brachial plexus, subclavian artery and osseous-ligamentous injuries). The mechanism of injury appears to be the delivery of severe rotational force sheering the shoulder girdle from its chest wall attachments around the scapula, shoulder joint and at the clavicle. Early recognition of the entity and aggressive treatment are crucial. Outcome is not dependent on management of the arterial injury, but rather on the severity of the neurological deficit.

Aneurysmal arterial disease in a patient with Ehlers-Danlos syndrome. Case report and literature review.

Multiple aneurysmal lesions and dissections of the right femoral artery in a young man with type IV Ehlers-Danlos syndrome are presented. Type IV results in a high incidence of vascular lesions-extreme fragility of arteries is associated with multiple aneurysm formation and spontaneous rupture and dissection of arteries. Surgical management of patients with this disorder is hazardous and often unrewarding. The successful surgical treatment of an acutely thrombosed aneurysmal femoral artery by means of an interposition graft, is presented and brief guidelines for the treatment and prevention of vascular complications are discussed.

Subclavian artery aneurysms. A report of 2 cases and a review of the literature.

True aneurysm of the subclavian artery is extremely rare and atherosclerosis is the most common cause. Syphilis, tuberculosis, and cystic medial necrosis are less often the cause. Their exact prevalence in the general population is unknown. These aneurysms can rupture, thrombose, embolize or cause symptoms by local compression. In reviewing the literature the great latency of the disease, high complication rate at presentation and the significant incidence, concomitant aneurysms elsewhere are emphasized. Duplex scanning followed by angiography should be performed in order to establish the diagnosis and to plan the operation. Elective surgical treatment is associated with little risk to the patient and avoids the need for emergency operations. Two cases of surgically treated true subclavian aneurysms are presented with review of the English language literature on the subject.

Acute thrombosis of an aortic aneurysm.

The natural history of abdominal aortic aneurysms is to enlarge gradually. Associated complications are rupture, peripheral embolization and infection.1-5 Complete occlusion of an abdominal aortic aneurysm by thrombus is extremely rare and constitutes a surgical emergency, with an estimated mortality of 50%.1-5 We report a case of a patient with this very uncommon complication of abdominal aortic aneurysm and review the literature discussing its optimal identification and management.

Intraoperative intra-arterial urokinase therapy after failed embolectomy in acute lower limb ischemia.

BACKGROUND: Aim of this study is to evaluate the use of intraoperative intra-arterial urokinase infusion (IIUI) in overcoming residual thrombi after thromboembolectomy in acute lower limb ischemia. DESIGN: retrospective study over a 3-year period. SETTING: University affiliated hospital. PATIENTS: 21 patients with acute lower limb ischemia who underwent IIUI after embolectomy (18 transfemoral, 3 transpopliteal) had failed to achieve adequate distal perfusion. Postoperatively, all patients were maintained on full dose heparinization. MAIN OUTCOME MEASUREMENTS: complete or partial clot lysis on post-IIUI angiography; restoration of pedal pulses and a viable leg at discharge. RESULTS: Angiographically, complete and partial lysis was demonstrated in 14 and 3 patients, respectively. Two patients with prolonged ischemia required fasciotomy. One of these eventually had an amputation. Altogether, limb amputations (1 above knee, 2 below knee) were necessary in 3 patients. The angiographic appearance of lysis correlated well with the restoration of pedal pulses and/or limb viability. One patient died of myocardial infarction 3 days after the procedure. Postoperatively, there were 5 (24%) wound hematomas of which 1 required surgical exploration. Over a mean follow-up period of 8 months (range 1-16), limb salvage was sustained in the 17 patients with successful angiographic lysis. CONCLUSIONS: IIUI is an effective therapeutic adjunct to failed embolectomy in acute lower limb ischemia. Use of this procedure is recommended as part of the routine management in such cases.

Isolated femoral profundoplasty using endarterectomised superficial femoral artery for limb salvage in the elderly.

BACKGROUND: The deep femoral artery provides the primary blood supply to the thigh, and in addition serves as the major collateral channel for bypassing the obstructed superficial femoral artery. The purpose of isolated profundoplasty is to relieve a significant stenosis and improve perfusion of the ischaemic leg. METHODS: Twenty-seven patients with critical limb ischaemia underwent isolated profundoplasty in the Vascular Unit of Meir General Hospital, using endarterectomised superficial femoral artery (ESFA) as an arterial patch. Nineteen patients were men. The average age was 72 (65-79). The presenting symptoms: rest pain: 18 (67%), ischaemic foot ulcer: 7 (28%), pedal gangrene: 2 (7%). Selection criteria for isolated profundoplasty: 1) > 50%: stenosis of arteria profunda femoris lumen. 2) Adequate profunda: popliteal collateral system. 3) Adequate arterial inflow: common femoral artery. RESULTS: There was no operative mortality or immediate operative failure. All 27 limbs were improved: relief of rest pain, healing of ischaemic ulcers and good healing after minor amputations (transphalangeal, transmetatarsal). Follow-up period ranged from 12 to 45 months (mean 30 months) and was based on clinical investigation + ankle/brachial Doppler measurements. All patients remained asymptomatic with improvement of limb function--either to the present or until their death. CONCLUSIONS: In view of our favourable experience, we feel that isolated profundoplasty still has a place in vascular surgery practice--when limb revascularization in elderly patients considered at high risk is dangerous and when there is impossible below knee vascular reconstruction. We recommend the use of ESFA as a patch for long segment profundoplasty--with all advantages of an autogenous material.

Hypnosis and the treatment of Huntington's disease.

Huntington's Disease is an inherited fatal disorder of the central nervous system. Literature on the hypnotic treatment of this disease is extremely sparse. We treated two patients with Huntington's Disease using a wide variety of hypnotic interventions. One patient was treated for a number of years and the other for 10 consecutive sessions. We discuss the continuously interacting cycle between the primary physical symptoms caused by the disease and the secondary psychological symptoms. Hypnotic techniques and daily self-hypnosis appeared to ameliorate both physical and psychological difficulties, thereby enhancing the quality of life that remained for the patients. Systematic research into the effectiveness of hypnosis with symptoms of Huntington's Disease needs to be undertaken in the future.

[The value of ceruletide in oral cholecystography]. / Intérêt du cérulétide en cholécystographie orale.

The action of Ceruletide, a decapeptide with a chemical formula close to that of the terminal acid amines of cholecystokinin pancreozymin, was investigated during oral cholecystography. Intramuscular injections of Ceruletide provoked gallbladder contractions that were stronger and occurred more rapidly than after the conventional "fatty meal". Visualization of the extrahepatic biliary pathways was improved, the duration of the examination shortened, and the number of films required reduced, the useful time in approximately 3 out of 4 cases being equal to or less than 6 minutes.

Brown bear (Ursus arctos arctos) femoral head and neck excision.

A 30-yr-old untamed European female brown bear (Ursus arctos arctos) with a craniodorsal luxation of the right femoral head and bilateral degenerative joint disease of the coxofemoral joint had a femoral head and neck excision following unsatisfactory conservative medical therapy. The bear was injected with zolazepam-tiletamine, and anesthesia was induced with i.v. thiopental and maintained with isoflurane in oxygen via endotracheal tube. A lumbosacral epidural injection of medetomidine-bupivacaine provided additional analgesia. Slight initial cardiorespiratory depression was counteracted with fluid and inotropic drug administration and ventilatory assistance. The bear's gluteal muscle anatomy differs from that of the dog. Recovery was uneventful. The bear was confined indoors for 6 wk and was able to ambulate normally within 6 mo.

[Chylous ascites imitating acute appendicitis].

Acute accumulation of chyle in the peritoneal cavity is rare. It is usually idiopathic and the diagnosis is made at laparotomy, when indicated because of signs of acute peritonitis. Drainage is the only treatment required and the prognosis is excellent. A 33 year-old man who was operated on for signs of acute peritonitis is described. There was more than a liter of chyle, but no underlying pathological condition was found. 3 months after discharge, physical and laboratory examinations were normal, with no evidence of chylomicron retention disease.

[Adenocarcinoma of the appendix].

Adenocarcinoma of the vermiform appendix is rare. It usually produces signs of acute appendicitis and is discovered only on pathological examination. The treatment of choice is right hemicolectomy, usually performed as a secondary operation. 2 cases of appendiceal carcinoma, in a 59-year-old man and in a 70-year-old woman, are described.

[Simultaneous aortic and renal revascularization in chronic renal artery occlusion].

The decision to revascularize an occluded main renal artery is often extremely difficult, especially when aortic and renal occlusive disease co-exist. The main objectives of surgery are preservation of renal parenchyma and possible amelioration of renovascular hypertension, provided the patient's condition permits. In a 52-year-old man with renovascular hypertension and intermittent claudication transfemoral aortography revealed severe atheromatosis of the aorta and iliac arteries. There was total occlusion of the left main renal artery, but the right renal artery was patent. Aorto-femoral bypass was performed using a bifurcated graft. The left kidney was revascularized using an 8-mm straight graft anastomosed end-to-end with the renal artery and the other end was inserted into the distal part of the bifurcated graft, constituting a triple bypass. The postoperative course was uneventful, blood pressure decreased and renal scan showed good left renal function. 6 months later aorto-bifemoral and renal bypass grafts were fully patent.

[Splenic subcapsular hematoma and long-term hemodialysis].

Uremic patients, or those on maintenance hemodialysis, are at increased risk for spontaneous bleeding. Manifestations include retroperitoneal, costal, hepatic, renal, pericardial, mediastinal and subdural hemorrhages. We describe 2 patients on chronic hemodialysis, a 45-year-old man and a 50-year-old woman. Each developed a subcapsular hematoma of the spleen, diagnosed by sonography and CT scan. They were conservatively managed by low-dose heparin, bed rest and careful monitoring. Frequently repeated ultrasound and CT scans demonstrated complete resolution of the hematomas after 2 and 4 months, respectively.

[Vascular injuries in children].

Vascular trauma in children differs in some respects from that in adults. In infants and children the total blood volume is smaller, and despite effective compensatory mechanisms, critical blood loss is also smaller. Gentle and meticulous technical skill is needed to correct injuries of minute vessels and allow adequate blood flow. The use of synthetic tubes and materials is not recommended, as they do not lengthen as the child grows. Ischemia is a major factor influencing limb growth and function. 3 different types of vascular injuries operated on in the past year are presented.

[Ultrasonic examination of the abdominal wall in surgery].

Ultrasonic (US) examination is a simple, effective and quick method of investigating the abdominal wall. We evaluated various cystic and solid lesions in 26 patients by US. In 24 the US diagnosis was correct and revealed pathologic conditions of the abdominal wall such as abscesses, cellulitis, metastatic tumors and hematomas. In 2 patients lesions of the abdominal wall were missed. All but 3 patients were treated surgically.