Recommendations for the diagnosis and management of vaccine-induced immune thrombotic thrombocytopenia.

There have recently been safety concerns regarding an increased risk of vaccine-induced immune thrombotic thrombocytopenia (VITT) following administration of SARS-CoV-2 adenoviral vector vaccines. The Southern African Society of Thrombosis and Haemostasis reviewed the emerging literature on this idiosyncratic complication. A draft document was produced and revised by consensus agreement by a panel of professionals from various specialties. The recommendations were adjudicated by independent international experts to avoid local bias. We present concise, practical guidelines for the clinical management of VITT.

Vascular surgical education in a medium-income country.

Medium income country such as South Africa face a dilemma on the need to offer high quality vascular surgical care in a resource constrained environment, where the vast majority of population has inadequate access to even the most basic health care provision. At the same time with rapid development in technology there is also the need to provide high technological treatment to a small population that can afford high cost therapy. This apparent dichotomy in health care provides a challenge and the solution is for all role players in the health care provision to find a solution which will suite the population at large.

Proximal suture line support in open abdominal aortic aneurysm repair: a comparative study.

OBJECTIVES: The aim of this study was to determine whether the collar graft (standard dacron graft with a customized flexible collar attached to the proximal rim) decreased anastomotic bleeding and the overall clamp time. DESIGN: Prospective randomised single center study. METHODS: Between November 2003 and January 2006, 21 patients were treated with a collar graft and 19 with a standard dacron graft. Routine endoaneurysmorraphy was used. Only infra-renal aneurysms between 5.5cm and 6.5cm were included. Aneurysms were diagnosed by CT scans. The total number of bleeding points, the total clamp time, and the number of teflon felt pledgets, was determined. RESULTS: The total number of bleeding points; the number of aortic re-clamps and total clamp time (minutes) per patient were all significantly lower in the collar graft group (1.2 versus 2, p<0.04; 0.5 versus 2.0, p<0.001; 13.6 versus 20.1, p<0.003 respectively). The number of teflon felt pledgets and new sutures used was significantly lower in the collar graft group (p<0.001 and p<0.003 respectively). CONCLUSION: The collar graft resulted in fewer anastomotic bleeding points and a shorter clamp time.

Aneurysms of the persistent sciatic artery.

The persistent sciatic artery is a rare anatomical anomaly of the lower limb vasculature. It may be noted incidentally, or it may present with limb ischaemia or aneurysmal degeneration. Management entails exclusion of the aneurysm and vascular reconstruction. A case of bilateral persistent sciatic artery aneurysms and a review of the embryological development, clinical features, and management are reported. The persistent sciatic artery (PSA) may result from an aberration in the development of the arterial supply to the lower limb. It is a rare anomaly, with sporadic cases reported in the literature, few of which have been angiographically documented. A report of a patient treated at King Edward VIII Hospital, Durban, is presented here.

Carotid endarterectomy after recent stroke--how soon? An interim analysis.

AIM: To determine whether timing of carotid endarterectomy (CEA) was significant in terms of morbidity and mortality for significant carotid stenosis in a prospectively evaluated cohort of patients with recent stroke. METHODS: A tailored protocol using contemporary neuro-imaging modalities including transcranial Doppler and non-invasive angiography. Standardised clinical scores, neurological deficit scores, an aetiopathogenic scale and disability stroke scales were used in the two group. Statistical analysis was done to compare differences in two groups: CEA done less than 6 weeks after stroke (group 1) and CEA done more than 6 weeks after stroke (group 2). RESULTS: Patients formed part of the Durban Stroke Data Bank (N = 655), with 26 patients in group 1 (CEA a mean of 16 days after stroke) and 34 in group 2. There were no statistically significantly differences between the two groups with regard to demographic factors, clinical scales, neurological deficit scores and investigate findings. There was 1 post-CEA stroke and 1 death in each group (P = 0.781), which was not significantly different. CONCLUSION: Timing of CEA after stroke may be unimportant with regard to mortality and morbidity in patients with relatively small stable neurological deficits. Other causative factors, as yet unclear, remain to be identified.

Pigment-induced nephropathy after sjambok injuries.

During a 12-month period, 42 patients required admission to hospital after sjambok beatings. Eighteen showed no abnormality of serum electrolyte values or renal function but urinary pigment precipitation was present in 9 patients. A further 16 patients demonstrated abnormalities of serum urea and electrolyte values, the commonest of which was a subnormal venous carbon dioxide content, in conjunction with urinary pigment precipitation in 14 cases. The remaining 8 patients presented with, or developed, varying degrees of renal failure. In 4 of these patients, the sole initial biochemical abnormality was a subnormal venous carbon dioxide level. Based on the initial laboratory findings, four groups of patients may be identified with gradations of soft-tissue injury. Recognition of those patients at risk of developing crush syndrome is facilitated and appropriate treatment may be instituted at an early stage thereby reducing morbidity and mortality.

Management of proximal axillary and subclavian artery injuries.

BACKGROUND: The aim of this study was to review the management and outcome of proximal axillary and subclavian artery injuries, and to estimate the prehospital mortality rate for subclavian injury through forensic pathology autopsy data. METHODS: Data were collected prospectively for 260 patients who presented between 1977 and 1996 with trauma to the proximal axillary and subclavian arteries. RESULTS: The majority of victims (214, 82 per cent) were admitted following stab injury. Some 154 patients (59 per cent) presented within 24 h of sustaining an injury and, of these, 59 (38 per cent) required immediate surgery. An additional 67 patients (26 per cent) attended 2 days or more after injury. Comparison of these data with those from forensic autopsy reports suggests that the prehospital mortality rate for penetrating subclavian trauma was approximately 75 per cent. CONCLUSION: Approximately 25 per cent of subclavian artery injuries caused minimal initial symptoms but delayed complications prompted attendance for medical attention. The majority of patients who survived subclavian artery injury and attended for medical attention were haemodynamically stable on admission; selective arteriography provided valuable information in these patients. Supraclavicular and infraclavicular incisions avoided clavicular division and reduced the postoperative morbidity associated with distal subclavian artery injuries.

Colour-flow ultrasound in the detection of penetrating vascular injuries of the neck.

PURPOSE: To determine the sensitivity of colour-flow ultrasound in the detection of penetrating vascular injuries of the neck when compared with conventional angiography. METHOD: We prospectively imaged the neck arteries of all patients with suspected vascular injuries who were referred for angiography by the vascular surgeon over a 6-month period. All sonograms were performed by the same radiologist before angiography using a 7.5 or 10 MHz transducer on the same scanner. Data recorded were the presence or absence of vascular injury, the site of injury, and the type (intimal, dissection, false aneurysm or fistula). Angiography was performed immediately afterwards by a different radiologist. Results were correlated with the angiogram and operative findings. RESULTS: 25 patients were studied. 15 patients had normal ultrasound studies and angiograms. Ultrasound studies were positive in 10 patients (40%), with false aneurysms and arteriovenous fistulas detected in 8 patients; these were confirmed on angiography and at operation. There were intimal injuries in 2 patients (4%) that were undetected on angiography but confirmed at surgery. There were no false-positive or false-negative ultrasound studies. CONCLUSION: Colour-flow ultrasound is sensitive in detecting vascular injuries and is suitable as a screening investigation in patients with penetrating neck injuries.

Haemostasis by angiographic embolisation in exsanguinating haemorrhage from facial arteries. A report of 2 cases.

Life-threatening exsanguinating haemorrhage from arteries of the face following trauma is uncommon. When it occurs it is often located in the relatively inaccessible parts of the vessels and requires deep face or neck exploration and ligation of the main feeding vessel. The procedure requires expert head and neck vascular surgery performed under general anaesthesia, which is often not suitable in these haemodynamically unstable patients. In addition, surgery is often rendered more difficult by the associated post-traumatic swelling and disfigurement. Because of these considerations, angiographic embolisation of the bleeding vessels was performed as an alternative to surgical exploration. This report illustrates its use in achieving haemostasis in 2 patients.

Surgical excision of scalp mycetoma due to Nocardia.

A 60-year-old patient presented with a mycetoma of the scalp with multiple chronic sinuses due to nocardiosis of the scalp. Recurrent bleeding from the sinuses necessitated surgical excision which led to a gratifying result. The case illustrates the importance of fungal culture in the diagnosis of cutaneous lesions and emphasises the role of surgery in mycetoma that are resistant to conventional therapy.

Gunshot injuries of the popliteal artery.

BACKGROUND: Guidelines for the management of popliteal artery trauma emanate mainly from military experience. This study was undertaken to describe the management of popliteal injuries in a civilian vascular surgical unit with a large trauma workload. METHODS: A retrospective review of records of patients treated between 1983 and 1997 was undertaken. RESULTS: Some 117 popliteal artery gunshot injuries were treated (83 low velocity, 16 high velocity, 18 shotgun). Associated fractures occurred in 44 patients and 40 had popliteal vein injuries. Treatment of the arterial injury included vein graft interposition in 71, primary reanastomosis in 19, prosthetic graft interposition in four, lateral suture in one, vein patch in one and ligation in one patient; 84 fasciotomies were performed. No perioperative deaths occurred. There were 20 primary and 14 secondary amputations. Factors associated with amputation were high-velocity injuries, delay in revascularization in excess of 7 h, arterial transection, associated fracture, and compartment syndrome or muscle infarction. CONCLUSION: Civilian popliteal gunshot injuries are attended by a high amputation rate. Prompt resuscitation and revascularization appear to be the only correctable factors that may improve limb salvage rates.

Selective conservative management of abdominal gunshot wounds: a prospective study.

A prospective study of 111 patients with low velocity gunshot wounds of the abdomen was conducted to determine whether a policy of selective conservative management based on repeated physical examination is a safe form of treatment. Laparotomy was undertaken in 89 patients (80 per cent), seven of which were negative. Of the patients 22 (20 per cent), eight of whom were considered to have peritoneal penetration, underwent conservative management. None required delayed laparotomy. Eight patients (7 per cent) died, all deaths occurring in the positive laparotomy group. The incidence of significant intra-abdominal injury if the peritoneal cavity had been penetrated was 89 per cent. Selective conservative management may be applied safely to a limited group of patients with gunshot wounds of the abdomen.

Management of graft occlusion following aortobifemoral bypass.

BACKGROUND: There is doubt as to whether operative mortality and subsequent graft patency and limb salvage rates support repeated efforts at revascularisation in patients with occluded aortobifemoral grafts. STUDY DESIGN: Prospective study of hospital patients with aortobifemoral graft occlusion presenting to the Durban metropolitan hospitals. The study was designed to assess outcome of revascularisation in these patients. METHOD: This is an analysis of 65 patients who developed graft occlusion out of a total of 492 aortobifemoral bypasses monitored over a 9-year period. Patients were investigated with angiography before being subjected to re-operation. They were followed up in the vascular clinic. RESULTS: The incidence of graft occlusion in this cohort was 15%. There were 11 early occlusions (2.6 days after the procedure) and 54 late occlusions (28 months after the procedure). Eight early graft occlusions were managed by means of thrombectomy, 1 with additional profundoplasty, and 3 were managed conservatively. Late complications were graft occlusion (1), graft sepsis (1) and aorto-enteric fistula (1). Late graft occlusions were managed by crossover (18), profundoplasty (7), axillo-femoral bypass (5), graft limb reconstruction (5) and redo procedures (2); 20 patients were managed conservatively. There was 1 postoperative death among the patients who experienced early occlusion, and none among those with late occlusion. Long term complications included secondary graft occlusions (3), graft sepsis (1) and amputations (5). The limb salvage rate was 63%. CONCLUSION: This study has shown that acceptable results can be achieved with surgery for graft occlusion following aortobifemoral bypass and that different treatment options are available.

Evaluation of factors influencing survival in ruptured aortic aneurysms.

During the six year period ending in December 1986, 103 patients with ruptured abdominal aneurysms presented to the unit. Ninety-two patients underwent surgery with a mortality of 39%. There was an increase in mortality with preoperative risk factors, extent of surgery, prolonged stay in ICU, complications and amount of blood transfused. However, only the latter was statistically significant. Age, the distance traveled by the patient before arrival at the hospital, systolic blood pressure on presentation and duration of operation did not affect the mortality.

Ruptured aortic aneurysms: postoperative complications and their management.

Postoperative complications in 92 patients undergoing repair of ruptured abdominal aortic aneurysms are reviewed. Renal failure and cardiac complications were fatal in 74% and 85% of the patients, respectively. Preoperative renal function at the time of presentation had no correlation with the development of renal failure. All but one patient in whom the left renal vein was divided developed renal failure postoperatively. There also was a preponderance of this complication in the patients needing suprarenal aortic control. Respiratory complications were seen in 29% of patients with 22% mortality. Peripheral emboli and ischemic colitis developed in 8% and 9% of the patients, respectively.

Aortic arch angiography prior to carotid endarterectomy. Is its continued use justified?

UNLABELLED: Patients with significant stenosis at the carotid bifurcation are traditionally subjected to four vessel aortic arch angiography prior to consideration for carotid endarterectomy. The advent of the non-invasive vascular laboratory has necessitated a reappraisal of this approach. AIMS: 1. Determine the yield from aortic arch angiography and its influence on surgical management. 2. Evaluate the accuracy of clinical examination and the non-invasive vascular laboratory in the detection of aortic arch branch lesions. METHODS: One hundred and twenty-nine consecutive patients undergoing evaluation for carotid endarterectomy were prospectively enrolled into the study. The protocol entailed: 1. Clinical recording of upper limb pulses, blood pressure and supraclavicular bruits. 2. Duplex scan examination to evaluate proximal inflow into the carotid arteries. 3. Four vessel aortic arch angiography to detect aortic branch lesions. Data from the non-invasive tests were compared to angiography. Patients with aortic arch branch lesions were further evaluated to determine the proportion requiring additional surgery. RESULTS: Nineteen patients had angiographic evidence of aortic branch disease (14.7%); six involved the common carotid artery, three the innominate artery and 10 the subclavian artery. All of these lesions were detected by the combination of unequal blood pressure, pulse deficit, bruit or duplex scan. Seven patients underwent additional surgery (5.4%) which included carotid-subclavian bypass (five), aortoinnominate bypass (one) and innominate endarterectomy (one). CONCLUSION: In patients with significant stenosis at the carotid bifurcation undergoing evaluation for carotid endarterectomy, aortic arch angiography is unnecessary except in a small percentage of patients with abnormal clinical and non-invasive findings.

Arterial reconstruction for non-specific arteritis (Takayasu's disease): medium to long term results.

There is little information on reconstructive arterial surgery for Takayasu Arteritis, and the approach is generally negative in this regard. Common causes of death are stroke, aneurysm rupture and the complications of renovascular hypertension and renal failure. The present study aims to examine the results of arterial reconstruction in the medium and long term in patients with histologically proven Takayasu's disease. In the last 11 years 134 patients have been referred to the vascular service of whom 81 (60%) were suitable for operation. Forty-nine were women; age range 3-45 years (average 29.5 years). In 28 the disease was confined to the aortic arch (Type 1); 41 had descending aortic involvement (Type II); six had a combination of arch and aortic disease (Type 111) and two associated cardiac lesions (Type IV). Four had isolated peripheral lesions (Type V). Seventy percent of these lesions were aneurysmal. Of the 28 type I patients, two had aortic arch reconstruction, seven segmental replacement. Of the 49 with type II, III and IV disease 26 had thoraco-abdominal aortic replacement using a bypass technique. The remainder had infrarenal aortic replacement and bypass procedures. Type V (four patients) had interposition grafts. Overall operative mortality in the Type I patients was 3.6% (stroke) and in the type II-IV 4%. All of the latter followed operation for aneurysm rupture and there were no elective deaths. Three months to 11 years after operation four patients (5%) developed fatal progression of the disease and seven (8.9) non-fatal disease progression of whom three required surgical intervention.(ABSTRACT TRUNCATED AT 250 WORDS)

Aneurysms due to intimomedial mucoid degeneration.

OBJECTIVE: Review management of patients presenting with aneurysms due to intimomedial mucoid degeneration (IMMD). DESIGN: Retrospective analysis. SETTING: Metropolitan Vascular Service, Departments of Haematology and Pathology, University of Natal. MATERIALS AND METHODS: Case records reviewed over an 11 year period. Twenty-two patients were submitted for surgery. All had histological confirmation of disease. All patients were black African (Negro) descent and nineteen were female. Average age was 52 years. RESULTS: Fifteen patients had involvement of descending aorta and seven patients had extra-aortic involvement. Hypertension was noted in half of the patients. Seven patients presented acutely with rupture (4) and ischaemic lower limbs due to dissection (3). Total absence of clot within aneurysm lumen was a distinctive finding on ultrasound, CT-scan and angiography. Treatment followed standard vascular surgical principles. Three patients died following emergency aortic replacement. Three patients developed severe intraoperative bleeding problems following elective aortic aneurysm resection due to primary fibrinolysis. All had normal preoperative coagulation profiles. CONCLUSION: IMMD is a rare disease affecting the intima and media of vessel wall involving aortic and extra aortic vessels, predominantly in younger African females with hypertension. Lack of clot within aneurysm lumen should alert surgeon to predisposition toward bleeding diathesis. Meticulous suture technique is essential as aortic wall is friable. Medium to long term results are satisfactory.

Long-term survival in patients undergoing resection of abdominal aortic aneurysm.

The long-term survival of patients undergoing abdominal aortic aneurysm surgery is presented. Three-hundred and thirty-eight patients who presented with elective, urgent, or emergency abdominal aortic aneurysms, have been followed retrospectively for five years. We found no statistical difference in the long-term survival in these three groups of patients. As expected patients who had successful operation survived better than patients who were not offered surgery because of their poor medical condition. Interestingly, advancing years, history of myocardial infarction or hypertension did not significantly influence long-term survival.