Abdominal aortic aneurysm rupture into a retro-aortic left renal vein.

We present a case of an abdominal aortic aneurysm ruptured into a retroaortic left renal vein. The patient presented with left flank pain, left-sided varicocoele and haematuria. Imaging showed a juxtarenal AAA associated with a retroaortic left renal vein and simultaneous contrast captation of the aneurysm, the vena cava, the left renal vein and the left vena testicularis. After opening of the aneurysm sac, the defect was controlled by digital pressure and closed by suture. The patient underwent a successful abdominal aorto bi-iliac replacement. We discuss prevalence, clinical features and treatment options of this rare condition.

Solitary splenic metastasis of an adenocarcinoma of the lung 2 years postoperatively.

Metastatic tumours of the spleen are rare and most frequently diagnosed at the time of autopsy. Most patients with splenic metastases have widely disseminated metastatic disease. We report a case of an asymptomatic, isolated splenic metastasis in a 67-year-old man diagnosed 2 years after resection of an adenocarcinoma of the lung.

Emphysematous pyelonephritis.

A case of emphysematous pyelonephritis with gas formation extending into the renal vein is presented. Diagnostic procedures and aggressive surgical management are discussed.

Occlusion of the left common femoral artery after total hip replacement. Report of a case and review of the literature.

Total occlusion of the left common femoral artery occurred after total hip replacement. Presumably the occlusion was caused by polymerization heat produced by the methyl-methacrylate. Only two similar cases have been reported previously. The vascular complications after hip surgery are discussed.

The persistent sciatic artery. A case report.

We describe a case of a complete persistent sciatic artery in an asymptomatic patient with multiple aortoiliac aneurysms. After endoaneurysmorraphy and ligation of the persistent sciatic artery at its origin, the patient did well, without ischaemic complications. Peripheral vascular reconstruction, although often recommended in the literature, did not seem to be indicated in this case.

[Approach in the treatment of combined aorto-iliac and femoro-popliteal lesions]. / Welke houding aannemen bij de behandeling van gekombineerde aorto-iliacale en femoro-popliteale letsels.

Recognition of the hemodynamic importance of aorto-iliac and femoro-popliteal stenoses or occlusions is essential for correct vascular reconstruction. Non-invasive examinations, arteriography, pressure- and flow-measurements add their value to clinical judgment and surgical experience. Practical guides are given to decide for one-level-reconstruction, concomitant or delayed two-stage-repair, or a combination of balloon-dilation together with arterial reconstruction.

Difficulties in the diagnosis of popliteal vein aneurysm.

Venous aneurysms are rare and seldom give rise to specific symptoms. We describe a case of a popliteal vein aneurysm in a 55-year-old patient in whom the lesion was at first misinterpreted as being a Baker's cyst. The lesion was successfully treated by segmental resection and venous interposition grafting.

Hazards of nasopharyngeal oxygen therapy: a case of iatrogenic stomach rupture.

Iatrogenic rupture of the stomach has been reported as a rare complication of nasopharyngeal oxygen therapy. A new case of this life-threatening condition is reported and diagnostic, therapeutic and preventive measures are briefly discussed.

[Membranous obstruction of the inferior vena cava]. / Membraneuze obstructie van de vena cava inferior.

A case of idiopathic membranous obstruction of the inferior vena cava (MOVC) is reported. Varicose veins of both lower limbs associated with dermatitis and venous ulceration were the presenting symptoms. Diagnosis was made by cavography after phlebography of both legs had revealed a normal deep system. Ultrasonography demonstrated a 4 mm thick membrane in the inferior vena cava just above the level of the hepatic veins. Stripping of the greater saphenous vein and ligation of incompetent perforating veins was performed to partially correct the venous insufficiency of the most affected limb. The patient refused further treatment of the MOVC. Concise review of the literature. Up to date therapeutic possibilities are discussed.

[The surgical treatment of aneurysms of the descending thoracic aorta]. / De chirurgische behandeling van aneurysmata van de aorta thoracalis descendens.

Between June 1983 and December 1987, 52 patients underwent resection of a thoracic descending aortic aneurysm. Thirty-day mortality was 11.5%; 4.8% for elective cases and 36.5% for patients operated upon in emergency. Spinal cord injury was present in two patients (4%). One patient was paraplegic, the other showed mild paraparesis, which was completely resolved. Both patients were operated for ruptured aneurysms. Severe postoperative renal dysfunction was present in 4 patients (7.5%) and was strongly related to intraoperative hypotension. The cumulative proportional survival rate was 81% at one year and 66% at two years of the total group, 85% at one year and 72% at two years for the patients presenting with nonruptured aneurysms. Aneurysms of the thoracic descending aorta can be resected with an acceptable mortality and morbidity. Just as in abdominal aneurysms, surgery definitely improves the outcome for these patients, who have a rather poor prognosis if left untreated.

A higher dose of vancomycin in continuous infusion is needed in critically ill patients.

Compared with intermittent infusion, continuous infusion of vancomycin is cheaper and logistically more convenient, achieves target concentrations faster, results in less variability in serum vancomycin concentrations, requires less therapeutic drug monitoring and causes less nephrotoxicity. Given that critically ill patients may develop very large volumes of distribution as well as supranormal drug clearance, in this study it was shown, despite the limited number of patients studied, that to achieve a target plateau concentration of 25mg/L a daily dose of 3000 mg of vancomycin in continuous infusion is needed following an appropriate loading dose.

Classic biphasic pulmonary blastoma: a case report and review of the literature.

Pulmonary blastomas are rare malignant tumors, comprising only 0.25-0.5% of all malignant lung neoplasms. Pulmonary blastomas are subdivided in three categories: well-differentiated fetal adenocarcinoma (WDFA), classic biphasic pulmonary blastoma (CBPB) and pleuropulmonary blastoma (PPB), which is currently regarded as a separate entity. The majority of patients with CBPB and WDFA are adults with an average age of 43 years. Tobacco use is identified as a causative agent. Symptomatology varies from asymptomatic (40%) to symptoms of a non-specific pulmonary disease. The most common roentgenologic pattern is a large peripheral nodule. The treatment of choice is surgical excision. The efficacy of adjuvant chemotherapy and radiotherapy is not yet established. The prognosis of pulmonary blastoma is very poor; overall five-year survival is 16%. WDFA appears to have a better prognosis. Adverse prognostic factors are biphasic type, tumor recurrence, metastasis at initial presentation, gross size of the tumor (>5 cm) and lymph node metastasis. On the basis of the available literature, an initial aggressive treatment that includes surgery and, wherever possible, postoperative chemotherapy and radiotherapy could be useful to prolong survival in patients with this rare lung neoplasm. We present a case of classic biphasic pulmonary blastoma in a 77-year old male and review the literature.

Isolation of a plasma protein observed in patients with essential hypertension.

In patients with essential hypertension, an additional plasma protein with an apparent molecular weight of 15,000 has been observed by high resolution sodium dodecyl sulphate polyacrylamide gel electrophoresis in the presence of beta-mercaptoethanol. Gel filtration on Sephacryl S-300 superfine revealed a native molecule with a molecular weight of 105,000. After reduction of the disulfide bridges with beta-mercaptoethanol the native molecule is dissociated into two subunits of 45,000 and one of 15,000. The native plasma protein has been purified by a combination of gel filtration on Sephacryl S-300, affinity chromatography on Concanavalin A Sepharose and anion exchange chromatography on DEAE-Sepharose. This protein has been referred to as "hypertension associated protein" (HAP).

Surgical correction of descending thoracic aortic aneurysms under simple aortic cross-clamping.

Between June 1983 and December 1987, 52 patients underwent resection of a descending thoracic aortic aneurysm under simple aortic cross-clamping without the use of shunting or bypass techniques. The 30-day mortality rate was 11.5%; 4.8% for elective cases and 36.5% for patients operated on in emergency. Two patients (4%) had spinal cord injury. One patient had paraplegia, and the other had mild paraparesis but completely recovered. Both patients were operated on for ruptured aneurysms. Four patients (7.5%) had severe postoperative renal dysfunction that was strongly related to intraoperative hypotension. The cumulative proportional survival rate was 81% at 1 year and 66% at 2 years for the total group. 85% at 1 year and 72% at 2 years for the patients first seen with nonruptured aneurysms. Aneurysms of the descending thoracic aorta can be safely resected without the use of shunting or bypass techniques. Surgery definitely improves the outcome for these patients who have a poor prognosis if left untreated.

Clinical experience with prolonged combined hemoperfusion-hemodialysis treatment of severe poisoning.

Fifteen patients with severe drug intoxication have been treated by a procedure combining hemoperfusion (HP, cellulose-coated activated charcoal, Adsorba C300, Gambro, Sweden) and hemodialysis (HD). The combined HP-HD treatment resulted in a clearance for amobarbital of 121 +/- 10 ml per min (mean +/-SEM), butobarbital 142 +/- 4 ml per min, carbromal 121 +/- 6 ml per min, hexobarbital 181 +/- 13 ml per min, meprobamate 145 +/- 9 ml per min, methaqualone 137 +/- 5 ml per min, phenobarbital 138 +/- 4 ml per min, and secobarbital 125 +/- 4 ml per min. There was no decrease in drug extraction even after 30 hours of treatment. Duration of treatment (6 to 33 hours) was determined by the clinical state of the patient. Prolonged HP-HD seemed to ben an efficient and sage procedure. Of 15 patients treated, 14 regained consciousness and 12 survived. The platelet count decreased, necessitating cessation of treatment in two cases. There was extraction of oxygen by the charcoal column, without influence on patient Po2. Glucose, urea, creatinine, uric acid, phosphate, and triglycerides were removed by adsorption on charcoal and/or dialysis.

Re-evaluation and modification of the Stuivenberg Hospital Acute Renal Failure (SHARF) scoring system for the prognosis of acute renal failure: an independent multicentre, prospective study.

BACKGROUND: A prognostic scoring system for hospital mortality in acute renal failure (Stuivenberg Hospital Acute Renal Failure, SHARF score) was developed in a single-centre study. The scoring system consists of two scores, for the time of diagnosis of acute renal failure (ARF) and for 48 h later, each originally based on four parameters (age, serum albumin, prothrombin time and heart failure). The scoring system was now tested and adapted in a prospective study. METHODS: The study involved eight intensive care units. We studied 293 consecutive patients with ARF in 6 months. Their mortality was 50.5%. The causes of ARF were medical in 184 (63%) patients and surgical in 108 (37%). In the latter group, 74 (69%) patients underwent cardiac and 19 (18%) vascular surgery. RESULTS: As the performance of the original SHARF scores was much lower in the multicentre study than in the original single-centre study, we re-analysed the multicentre data to customize the original model for the population studied. The independent variables were the score developed in the original study plus all additonal parameters that were significant on univariate analysis. The new multivariate analysis revealed an additional subset of three parameters for inclusion in the model (serum bilirubin, sepsis and hypotension). For the modified SHARF II score, r(2) was 0.27 at 0 and 0.33 at 48 h, respectively, the receiver operating characteristic (ROC) values were 0.82 and 0.83, and the Hosmer-Lemeshow goodness-of-fit P values were 0.19 and 0.05. CONCLUSION: After customizing and by using two scoring moments, this prediction model for hospital mortality in ARF is useful in different settings for comparing groups of patients and centres, quality assessment and clinical trials. We do not recommend its use for individual patient prognosis.