Intraoperative localization of small bowel bleeding sites with combined use of angiographic methods and methylene blue injection.

Superselective catheter placement with angiographic techniques and methylene blue injection at laparotomy through a prepositioned angiographic catheter have helped to localize small bowel bleeding lesions. The technique has been applied successfully in two patients with arteriovenous malformations and one patient with bleeding mucosal ulcerations of the small bowel.

Shoulder harness traction for roentgenographic assessment of the cervical spine.

We evaluated the clinical usefulness of a new shoulder traction device to facilitate a rapid complete cervical spine examination in an uncooperative patient population with multiple trauma. Forty-eight patients were randomly designated to receive the shoulder traction device or the standard technique (manual traction on the patient's upper extremities). Patient groups were equivalent in mean coma scale scores, trauma scores, age, and incidence of cervical fracture. Male-female ratios differed between groups, yet were biased against the harness technique. Fewer roentgenograms (lateral view) were required to visualize adequately all cervical vertebrae when the harness device was utilized (mean roentgenograms per patient, 1.2 vs 2.6; P less than .01). Shoulder harness traction during roentgenographic evaluation of the cervical spine may be a useful method to promote visibility of the lower cervical vertebrae.

Hemodialysis access in the pediatric patient population.

BACKGROUND: Each year, three to five children per million develop chronic renal failure. Of these, 70% will require dialysis for short periods, and 23% will require prolonged hemodialysis support. It is in the latter group that difficulty is encountered in establishing dialysis access. METHODS: From 1985 to 1992, we provided hemodialysis access for a group of 24 children. There were 16 boys and 8 girls, with a mean age of 11.1 +/- 4 years (range 3 to 17). All children were significantly below the 50th percentile weight for their age and sex. Seven children entered hemodialysis following failed peritoneal dialysis after an average of 21 +/- 10.5 months. Seventeen patients received a renal transplant. Seven of these children have resumed hemodialysis. RESULTS: The technique for establishing hemodialysis was varied: 15 arteriovenous fistulae, 37 expanded polytetrafluoroethylene (ePTFE) bridge grafts, 9 bovine arteriovenous bridge grafts, and 29 chronic central venous catheters. The overall mean functional patency of the fistulae was 6.2 +/- 10.2 months. One third of these fistulae failed to mature sufficiently to permit their use for dialysis purposes. Twenty-one upper extremity ePTFE grafts were implanted, with a mean functional patency of 11 +/- 11.1 months. Sixteen groin loop grafts were utilized, with a primary patency of only 4.1 +/- 5 months. Thrombectomy was performed in 25 cases (patch or interposition in 8 cases), with a secondary patency in these grafts of 10.5 +/- 17 months. An inability to achieve access in 2 children resulted in the creation of unusual types of access: an aorto-caval fistula and an axillo-femoral fistula and a combination of single-needle puncture of an immature fistula with one lumen of a PermCath. There were eight ePTFE graft infections, with graft loss occurring in seven cases. Superior vena caval occlusion occurred in two patients, inferior vena caval thrombosis in one patient, and axillo-subclavian venous occlusion in two patients. Development of central venous occlusions significantly increased the difficulty in establishing dialysis access. The total dialysis period provided by the 90 primary procedures performed in this study was 658 months. Each procedure, therefore, provided access for a mean duration of only 7.3 months. CONCLUSION: Providing dialysis access in the pediatric population is a time-consuming and frustrating challenge. We believe that all patients with renal dysfunction should have their conditions managed as potential long-term dialysis candidates. Therefore, our philosophy is to achieve maximal use from each access site. Although the primary patency of upper-arm ePTFE grafts was greater than that for the forearm fistulae in this study, failure of the upper-arm graft can result in loss of that limb for the purposes of future dialysis access. Consequently, we strongly advocate the "distal before proximal" and "autogenous before prosthetic" dogma in providing pediatric hemodialysis access.

Surgical rescue for failures of cirrhotic sclerotherapy.

Bleeding from gastroesophageal varices remains the most devastating complication of the portal hypertensive syndrome. Endoscopic sclerotherapy has emerged as the best initial treatment for bleeding varices because surgery is obviated and survival may be improved. However, sclerotherapy will fail and surgical rescue will be required in at least a third of patients. There are two viable surgical rescue procedures: shunt surgery and liver transplantation. This paper summarizes the available data and concludes that there is a role for both procedures.

Peripheral vascular complications of aortic dissection.

BACKGROUND: The incidence and management of peripheral vascular complications of aortic dissection is unsettled. PATIENTS AND METHODS: Peripheral vascular complications of spontaneous aortic dissection were examined in a 5-year retrospective review. Patients who had peripheral vascular complications were categorized as group A; those without as group B. RESULTS: Thirty-eight major vessels were affected in 18 patients. No patient underwent a peripheral vascular procedure for complications of the carotid, subclavian, celiac, mesenteric, or renal arteries. Three patients underwent femorofemoral bypass for acute iliofemoral occlusion due to dissection. A fourth patient had repair of an iliac aneurysm that developed as a complication of chronic dissection. The mortality rate was 17% for group A, 9% for group B, and 10% overall. Following repair of the aortic dissection, the majority of the peripheral vascular complications resolved. CONCLUSIONS: Peripheral revascularization is infrequently required in aortic dissection following primary dissection repair.

Surgical anatomy of hepatic transplantation.

Hepatic transplantation was pioneered by the work of Starzl and colleagues, first at the University of Colorado and later at the University of Pittsburgh. With the meeting of the National Institutes of Health (NIH) Consensus Development Conference in June of 1983, and their conclusion that liver transplantation was no longer experimental, orthotopic liver transplantation entered the "modern era." The release of cyclosporine by the US Food and Drug Administration (FDA) to transplant centers around the country, at the end of 1983, allowed for significant expansion of hepatic transplantation programs. Hepatic transplantation remains, however, the most difficult and complex of all solid organ transplants. A thorough grounding in the anatomic variations of hepatic segmental, arterial, venous, and ductal anatomy is only the first step in the successful completion of this challenging procedure.

Vascular complications following intra-aortic balloon pump insertion.

The intra-aortic balloon pump (IABP) has been used for 23 years to treat cardiogenic shock from various causes. A retrospective review was conducted to evaluate the morbidity, mortality, and risk factors associated with insertion of this device. Over a recent 3-year period, 415 such pumps were inserted either by percutaneous (323) or cut-down (92) technique in 404 patients. Indications for placement included intraoperative pump failure (46%), cardiac instability before coronary artery bypass grafting (28%), perioperative support (13%), cardiac transplantation (7%), and cardiogenic shock (6%). Noncardiac vascular complications occurred in 67 patients, 55 per cent of whom required surgical correction. Operative procedures included femoral artery thrombectomy, bypass grafting, fasciotomy, and amputation. Major risk factors for vascular complications included diminished or absent femoral pulses on initial examination, being a woman, and obesity. In patients with known peripheral vascular disease, the risk of a vascular complication was 17.9 per cent when a surgical cut-down technique was used to insert the IABP, and 38.9 per cent when a percutaneous insertion was performed. The mortality doubled in those patients who had a vascular complication as compared to those who did not (34% vs 17%). A more liberal use of an open surgical technique in those patients with peripheral vascular disease, obesity, and who are women may help to reduce complications after the insertion of the intra-aortic balloon pump.

A prospective evaluation of surgically treated groin complications following percutaneous cardiac procedures.

During an 18-month study period, 100 noncardiac surgical complications of a percutaneous cardiac interventional procedure were treated at Emory University Hospital. These were predominantly pseudoaneurysms (61.2%), groin hematomas (11.2%) arteriovenous fistulae (10.2%), and external bleeding (6.1%). Less common complications included retroperitoneal hematomas (5.1%), arterial thromboses (3.1%), groin abscess (2.0%), and a mycotic pseudoaneurysm (1.0%). The complication rate following diagnostic catheterization was 0.6 per cent, after percutaneous transluminal angioplasty, 1.5 per cent, atherectomy 2.2 per cent, and after stent placement 16 per cent (P < 0.0001). The arterial puncture site was other than the common femoral artery in 34 per cent of cases. Risk factors for the development of complications were postprocedure anticoagulation (P < 0.0001), female gender (P < 0.005), increased age (P < 0.0001), and small stature (P < 0.0001). Duplex scanning had 98 per cent accuracy in diagnosis of suspected groin complications, and clinical diagnostic accuracy was 77 per cent. We describe our technique for repair of pseudoaneurysms and arteriovenous fistula and discuss the possible future role of ultrasound guided compression. Mean hospital stay after the procedure was 3.2 days. Morbidity of surgical repair was 21 per cent and mortality was 2.1 per cent. Groin complications following percutaneous cardiac procedures are related to the type of procedure performed, female gender, and periprocedure anticoagulation.

Retroperitoneal hematoma following femoral arterial catheterization: a serious and often fatal complication.

Retroperitoneal hematoma (RPH) following cardiac catheterization is an infrequent (0.15% incidence) but morbid complication. During a 13-month study period, 11 patients with a significant RPH requiring operative intervention were identified. The mean transfusion requirement was 8.7 units, with two deaths as a consequence of their RPH. Adjunctive cardiac procedures included percutaneous transluminal coronary angioplasty (five), stent placement (one), and thrombolysis (two). Two patients had RPH following aortography. Suspicion of RPH was most frequently prompted by a falling hematocrit (73%), with hypovolemic shock (systolic blood pressure < 90) in 64%. Lower quadrant or flank pain occurred in four patients. Lower extremity pain occurred in five patients due to femoral nerve compression. Of six patients with a preoperative femoral nerve palsy, complete resolution occurred in four cases. RPH following femoral arterial puncture is a cause of significant morbidity, particularly in the anticoagulated patient. Postcatheterization anticoagulation and high arterial puncture were the principal risk factors (p < 0.001). Early recognition is essential and should be prompted by a falling hematocrit, lower abdominal pain, or neurological changes in the lower extremity. There should be a low threshold for performing abdominopelvic CT scans in such patients. Management of RPH must be individualized: 1) patients with neurological deficits in the ipsilateral extremity require urgent decompression of the hematoma, 2) anticoagulation should be stopped or minimized, 3) hematoma progression by serial CT necessitates surgical evacuation and repair of the arterial puncture site.

Pediatric liver transplantation in Georgia: a paradigm for the health care crisis in the United States?

The United States health care system, felt by many to be the most technologically advanced program in the world, has many critics. Two indisputable facts that drive such criticism are 1) inequitable access and 2) rising costs out of proportion to other countries. Although Georgia is a poor state and ranks nationally near the bottom in most measures of child and adolescent care, we decided to start a pediatric liver transplant program at Egleston Children's Hospital at Emory, Atlanta. Over the past 2 1/2 years, 18 transplants have been performed in 14 patients; 10 children are presently surviving. Looking carefully at the expenses of the first 10 patients, the average cost of orthotopic liver transplantation for the eight survivors was $206,375. The hospital costs for providing care to these 10 children were over $2 million. In a state that ranks 49th out of 50 states in infant mortality and with nearly one-third of its pre-school children not immunized against preventable diseases, is this a fair and equitable distribution of our resources?

Polytetrafluoroethylene aorta-vena cava graft for hemodialysis: report of a case.

In children with chronic renal failure, vascular access for hemodialysis is difficult because of the small size of the vessels and the requirement for substantial blood flow through the fistula or graft. As the child grows older, the ease of constructing a satisfactory access usually increases as the vessels increase in size. Unfortunately, this increased ease is often offset by the paucity of suitable access sites because the larger peripheral sites have already been used with only transient success. We report a child with chronic renal failure since 1 month of age with no peripheral sites available because of prior failed procedures who underwent placement of polytetrafluoroethylene limbs to the aorta and vena cava at the age of 6 years. He has continued on hemodialysis for the past 4 1/2 years with this technique of vascular access.

Hemodynamics during liver transplantation: the interactions between cardiac output and portal venous and hepatic arterial flows.

Liver blood flow and systemic hemodynamics were measured intraoperatively in 34 patients after liver transplantation. Ultrasound transit-time flow probes measured hepatic arterial and portal venous flow over 10 to 75 min 1 to 3 hr after reperfusion. Cardiac output was measured by thermodilution. Mean cardiac output was 9.5 +/- 2.8 L/min; the mean total liver blood flow of 2,091 +/- 932 ml/min was 23% +/- 11% of cardiac output. Mean portal flow of 1,808 +/- 929 ml/min was disproportionately high at 85% +/- 10% of total liver blood flow. Correlation analysis showed a significant (p less than 0.01; r = 0.42) correlation between cardiac output and portal venous flow and a trend toward negative correlation (p = 0.087) between cardiac output and hepatic arterial flow. These data show that increased flow in the newly transplanted liver is predominantly portal venous flow and is associated with high cardiac output and reduced hepatic arterial flow. In the last 13 patients studied, portal flow was reduced by 50% and the hepatic artery response was measured. We saw a significant (p less than 0.05) increase in hepatic artery flow from 322 +/- 228 to 419 +/- 271 ml/min, indicating an intact hepatic arterial buffer response. The hepatic artery response also showed that it is a reversible rather than a fixed resistance that contributes to the low hepatic artery flow in these patients.

Acute arterial thrombosis in the very young.

The case records of all infants under the age of 6 months who underwent surgery for acute arterial thrombosis between January 1980 and September 1991 were reviewed. Seven infants (nine ischemic limbs) were identified and ranged in age from 5 days to 5 1/2 months (mean 2.4 months); all weighed less than 5 kg (mean 3.9 kg). The cause in each case was iatrogenic. Diagnosis was based on the presence of a cool, mottled extremity associated with the absence of insonated peripheral arterial Doppler signals. Treatment included aortoiliac thrombectomy (n = 2), femoral artery thrombectomy with primary closure (n = 4), femoral artery thrombectomy with autogenous saphenous vein patch (n = 1), and axillary artery thrombectomy with end-to-end anastomosis (n = 1). Palpable pulses were restored in five (56%) of nine limbs and Doppler signals in the remaining limbs. There were no instances of limb loss. Excluding aortoiliac thrombectomy, palpable peripheral pulses were reestablished in only 40% of extremities. Thrombectomy is a safe and simple procedure in even the very youngest of patients with arterial insufficiency, but surgical optimism should be tempered by frequent inability to achieve full and durable success.

Renal cell carcinoma with inferior vena caval involvement.

Renal cell carcinoma extends into the lumen of the inferior vena cava in approximately 4% of patients at the time of diagnosis. Surgical removal of the intracaval tumor thrombus with radical nephrectomy is the preferred treatment for this malignancy. From January 1977 to June 1990, 31 such patients were examined for combined problems of renal carcinoma and intracaval tumor extension. Twenty-six of these patients underwent radical nephrectomy and vena caval thrombectomy. Ten patients had tumor thrombus confined to the infrahepatic vena cava, 11 had retrohepatic caval involvement, and 5 had extension to the level of the diaphragm or into the right atrium. Surgical approach was dictated by the level of caval involvement. Control of the suprahepatic vena cava plus temporary occlusion of hepatic arterial and portal venous inflow were necessary in some cases; cardiopulmonary bypass was required for transatrial removal of more extensive tumors. Five of the 26 patients had evidence before operation of distant metastatic disease; none of these survived beyond 12 months. The 5-year actuarial survival rate of the 21 patients without known preoperative metastatic disease was 57%. Complete surgical excision of all gross tumor appears to be critical for long-term survival in these patients.

Proximal abdominal graft for arterialization during hepatic transplantation.

A new method of arterial grafting during orthotopic hepatic transplantations is described herein. The advantages compared with other techniques include better exposure, less extensive dissection, reduced blood loss and, with correct anatomic orientation, a reduced risk of kinking the graft in a blind tunnel.

Endoluminal stent placement and coil embolization for the management of carotid artery pseudoaneurysms.

PURPOSE: To present a series of carotid artery pseudoaneurysms treated successfully using an endovascular approach. METHODS: From April 1995 to November 1999, 5 patients with neurological symptoms not explained by computed tomography of the head were identified by carotid angiography as having internal carotid artery (ICA) pseudoaneurysms. Three patients had sustained blunt trauma, and 2 had previous elective carotid endarterectomies for atherosclerotic disease. The time between injury and treatment ranged from 3 days to 10 years. The patients were treated with endovascular stent placement for exclusion of the pseudoaneurysm, followed by filling of the cavity with multiple detachable coils. Patients were maintained on oral antiplatelet agents or anticoagulant therapy after the procedure. RESULTS: Primary technical success was 100%. No patient suffered permanent neurological sequelae. Postprocedure angiography demonstrated a patent ICA in all cases, with complete obliteration of the pseudoaneurysm. At a mean 8.4-month follow-up (range 2-21), all patients remained symptom free; angiograms in 3 patients at a mean 11.7 months demonstrated continued ICA patency. One patient had a 60% focal narrowing of the distal common carotid artery, which was treated successfully with balloon dilation and stenting. CONCLUSIONS: Endovascular treatment of carotid artery pseudoaneurysms is a useful alternative to standard surgical repair. This modality avoids the necessity for surgical exposure at the skull base with its inherent morbidity.

Subclavian artery disruption resulting from endovascular intervention: treatment options.

Endovascular intervention is a commonly accepted form of treatment in patients with subclavian artery stenosis. Complications will undoubtedly occur as the utility of catheter-based intervention continues to rise. We report two cases of subclavian artery disruption as a result of endovascular intervention. One patient had contrast extravasation after the deployment of a balloon-expandable stent in a stenotic subclavian artery, and the arterial injury was successfully treated with balloon tamponade. A second patient had a large subclavian pseudoaneurysm 4 months after a balloon-expandable stent placement. Successful repair was achieved in this patient by means of arterial reconstruction with a prosthetic bypass graft. These cases illustrate different therapeutic methods of treating subclavian artery rupture due to endovascular intervention.