Outcomes for cervicomediastinal vascular trauma managed by a vascular subspecialistled vascular trauma service.

BACKGROUND: The management of cervicomediastinal vascular trauma is challenging. We report on our experience with the condition in a newly established vascular trauma service unit, and compare the outcomes to those reported in our parent vascular surgery department. METHOD: The details of patients with cervicomediastinal vascular injuries from January 2012 to June 2014 were retrieved for analysis from a prospective database. RESULTS: Ninety-three patients were identified, 84 of whom were male (90%), with an average age of 29 years. Most were penetrating injuries (89%), and 87% of these were due to stab wounds. There were 107 vascular injuries, 88 cervical and 19 mediastinal. Of these, 87 were arterial and 20 venous injuries. The most common arterial injury involved the subclavian artery (24%), followed by the common carotid artery (22%). Management was multimodal, and included conservative (8%), stenting and embolisation (8%), referral to a higher centre (8%), vascular repair (64%) and ligation (12%). Nineteen per cent required median sternotomy or thoracotomy. Eight patients died postoperatively (9%). Seven of them presented in extremis and died within 24 hours, and one died after a week from associated abdominal injuries. Postoperative complications were 9%. There was no incidence of a stroke or limb loss despite ligation of the arteries, including ligation of four internal carotids. CONCLUSION: The development of endovascular techniques would allow for noninvasive management of a significant number of patients. Open surgery is still necessary, and associated with significant morbidity. Comparable results were reported in our newly established vascular trauma service unit to those obtained in our parent vascular surgery department in Durban.

Management of HIV vasculopathy - a South African experience.

UNLABELLED: The aim of the study was to describe the presentation management and short term results of therapy (< 1 month) in patients admitted with HIV vasculopathy. Records were culled from a prospectively maintained data base on the Vascular Unit at Inkosi Albert Luthuli Hospital, Durban, South Africa between January 2005 and June 2009. 226 patients were studied; 111 had aneurysms and 115 occlusive disease. 98% were African and ages ranged from 4-53 years (average 36); 90% were male. The CD4 count ranged from 1-930 cells/mm(3) while serum albumin averaged 30 mMol/L. 202 aneurysm presented in 111 participants; commonest sites were superficial femoral artery (40%) and carotid (25%). 82 patients had standard operative repair and 8 had stent grafts; 29 were not treated due to advanced disease. Within 30 days of operation the mortality was 9% with 5% developing graft sepsis and 11% pulmonary complications. Of 115 with occlusive disease, there were 2 distinct groups. 51 had no previous claudication and had acute thrombosis; no thrombophilia could be demonstrated. 64 had premature atherosclerotic disease. The majority presented with critical ischaemia. In the acute thrombosis group 15 (29%) had primary amputation, limb salvage was achieved in 13 (36%) and 4 died (11%). In the chronic occlusive group 30 (47%) had primary amputation, of 25 submitted to surgery limb salvage was achieved in 17 (68%). Low CD4 count and albumin levels did not correlate with mortality or complications. CONCLUSION: Surgical therapy for aneurysm is worthwhile in the short term. Following occlusive disease there is a 25% overall salvage rate in the short term (< 1/12) but the long term outlook is uncertain.

Fluctuating pulse deficits associated with intimal arterial injury following gunshot wounds of the extremity--a sign not to be missed.

Gunshot wounds may result in intimal arterial injury without breach of the arterial wall integrity. Haemorrhage, haematoma and a pulse deficit are therefore not always found. We report on two cases of lower extremity gunshot wounds with temporal variations in the clinical and radiological assessment of the pedal pulses. In both cases surgical exploration revealed intact arterial vessel walls but significant intimal injury with overlying thrombus. We propose that the pulse deficits were due to distal thromboembolism. Subsequent clot lysis led to a return of the original pulse deficit. Variation in the distal pulses in patients with gunshot wounds of the extremities should alert one of the possibility of an intimal arterial injury; imaging of the vessels is therefore advised.

Comparison between superficial femoral artery stenting and bypass surgery in severe lower-limb ischaemia: a retrospective study.

BACKGROUND: Symptomatic femoro-popliteal disease is treated by bypass surgery or angioplasty with or without stenting. The aim of this study was to compare the results of stenting and bypass surgery with regard to limb salvage in patients with severe leg ischaemia. METHODS: A total of 213 patients with femoro-popliteal disease presenting with severe claudication or critical limb ischaemia between January 2009 and December 2013 were evaluated; 118 patients (139 limbs) had stents placed and 95 patients (104 limbs) had bypass surgery. Most (60%) presented with critical limb ischaemia (rest pain 40%, tissue necrosis 20%), and the remainder with severe claudication. The treatment groups had matching risk factors. RESULTS: The average age was 66 years and 73% were male. Tissue necrosis was found in 26% of the stent group and 12% of the bypass group (p = 0.009). In the stent group 26% had adjunctive procedures, compared to 16% in the bypass group (p = 0.138). During the one-year follow up, there were 30 stent occlusions (22%) and 18 graft occlusions (17%) (p = 0.42). There were 14 major amputations (10%) in the stent group, and 13 (13%) in the bypass group (p = 0.68). Limb salvage rate was 90% in the stent group, and 88% in the bypass group (p = 0.68). There were no peri-operative deaths in the stent group, but one in the bypass group (1%). One-year mortality rate was equal (8%) in both groups (p = 1.00). CONCLUSION: One-year outcome was comparable in both groups with regard to mortality, stent or graft patency and limb salvage rates.

Antibiotic prophylaxis in aortic and peripheral arterial surgery in the presence of infected extremity lesions. Results of a prospective evaluation.

Over a 6-month period 124 patients submitted to aortic or infra-inguinal arterial reconstruction were alternately allocated to receive cloxacillin plus gentamicin (CX/GM) for 48 hours or cefotaxime (CTX) for 24 hours perioperatively. Evaluations during during the first month were performed by a blinded independent observer and patients were followed for between 6 and 20 months. 63 patients received CX/GM and 61 CTX; the groups were matched for sepsis risk factors. Sepsis rates were: groin and abdominal wounds, CX/GM 5.4% (7 of 129), CTX 6.2% (8 of 127); graft, CX/GM 1.5% (1 of 63), CTX 3.3% (2 of 61). The differences were not statistically significant (p greater than 0.05). Virtually all wound infections were superficial (class I) and no late infections have emerged. 56 patients had infected extremity lesions and 68 had no lesion. There was no significant difference in wound or graft sepsis rates between the 2 groups. Positive cultures of groin lymph nodes and/or aortic clot or atheroma did not predispose patients to postoperative sepsis. The organisms cultured from the extremity lesions were not found in infected wounds of abdominal surgery patients. However, species type and antibiotic susceptibility patterns suggest that the same pathogens were present in wound infections as were isolated from the extremity lesions of patients who underwent infra-inguinal surgery. Thus direct, rather than lymphatic, contamination may be the major aetiological factor. Most infecting organisms were susceptible to the antibiotic used.

Cervicomediastinal arterial injuries. A surgical challenge.

The initial clinical observations and methods and results of treatment in 104 patients with subclavian (48), vertebral (four), and carotid (52) artery injuries are reported. Delayed hemorrhage ten days after misdiagnosed subclavian artery injuries resulted in false aneurysms causing compressive brachial plexus palsies. A conservative approach to penetrating cervicomediastinal wounds was adopted with selective use of arch aortography when arterial injury was suspected by defined criteria. This proved safe, accurate, and invaluable for planning operative approach. Partial median sternotomy without entering the pleura proved optimal for superior mediastinal access; simple clavicle transection provided adequate distal subclavian exposure. External carotid and vertebral arteries were ligated. No shunts were employed for common and internal carotid repair. None of the 14 patients revascularized in the presence of a neurologic deficit died and none was made worse by carotid reconstruction.

Surgical management of penetrating mediastinal arterial trauma.

Fifty-two patients with penetrating injury to the arteries caudal to the thoracic inlet and cephalad to the heart came under the care of the Durban Metropolitan Vascular Service, South Africa, over a 13-year period. The innominate artery was the commonest vessel injured (n = 23). Five patients (11%) had multiple vessel injuries, four of which involved the aortic arch, and 18 (34%) had arteriovenous fistulae. Mortality was greatest with injuries involving the aortic arch (n = 17) and ascending aorta (n = 4) in which intra-operative exsanguination was the leading cause of death (five patients). Injuries involving the inferior and posterior walls of the aortic arch and those located between the innominate and left common carotid origins were the most difficult to control. Seven patients with aortic injuries presented with cardiac tamponade, three of whom had associated injuries involving the atria. Seven of 21 (33%) patients with aortic injuries died compared to 2 of 31 (6%) with aortic arch branch injury (p < 0.05, chi-square) for an overall mortality of 17%.

Colour Doppler and grey scale ultrasound features of HIV-related vascular aneurysms.

Atypical aneurysms of large elastic arteries owing to human immunodeficiency virus (HIV) vasculopathy are a well described complication of acquired immunodeficiency syndrome (AIDS). However, there are no reports describing the ultrasound features of these lesions. We performed a retrospective review of ultrasound images of 12 patients presenting with 39 HIV-related aneurysms over a 2 year period. Of these there were a total of 12 patients with symptomatic lesions comprising the superficial femoral artery (n=5), the origin of the internal carotid artery (n=3), the popliteal artery (n=2), the common femoral artery (n=1) and the common iliac artery (n=1). The remainder were asymptomatic and were demonstrated radiologically. The ultrasound features of large symptomatic HIV-related femoral and carotid aneurysms were typical of pseudoaneurysms with a defect or "blow-out" in the vessel wall and turbulent pulsatile flow. Of note was the presence of marked thickening of the vessel adjacent to the aneurysm and hyperechoic "spotting" of the arterial wall. These ultrasound features described may be unique to HIV vasculopathy.

Septic erosion of the internal carotid artery. A case report.

A case of pseudo-aneurysm of the internal carotid artery with arterio-venous fistula formation, involvement of the vagus and sympathetic nerves and proptosis is described. The diagnostic features are stressed, namely: recurrent minor haemorrhages from the nose and throat, a Horner's Syndrome, a swelling resembling a quinsy and involvement of the last four cranial nerves. Early diagnosis and immediate ligation are essential in these cases.

Surgical management of mycotic aneurysms.

Mycotic aneurysms not associated with trauma or atherosclerosis are uncommon. Their clinical presentation is insidious and lacks definite diagnostic criteria. This retrospective study of 14 patients treated over a period of 9 years confirms this, and shows that half are associated with a predisposing infected focus and that the main presenting clinical feature is that of a painful mass (64%) which is often mistaken for some other diagnosis. The main extracranial, extrathoracic site of predilection was the iliofemoral segment (65%). The main diagnostic investigation was angiography, which was also used to uncover silent aneurysms elsewhere in the arterial tree. Urgent surgical treatment is mandatory since complications may occur at any time and these may include life-threatening bleeding. Two of our patients experienced life-threatening gastro-intestinal bleeding while in hospital. The mainstay of treatment was surgical resection and reconstruction using an autologous vein or artery if possible. The more serious complication of graft failure was encountered mainly in patients who underwent prosthetic graft repair. It is in this group that 2 of the 3 early postoperative deaths occurred, from graft thrombosis and mesenteric infarction. Overall, surgical repair was attended with good outcome (77%).

Aortobifemoral bypass for the critically ischaemic limb--is it worth while?

Little is written of the place of aortobifemoral bypass as a limb or below-knee-level amputation stump salvage procedure in patients presenting with critical ischaemia with threat of limb loss. Over a 4-year period 151 patients referred to the Vascular Service of the University of Natal Hospitals with aorto-iliac occlusive disease and a threatened limb were studied. All were submitted to aortobifemoral bypass. Patients were divided into two subgroups: group 1 patients presented with rest pain or focal necrosis and were submitted to aortobifemoral bypass with concomitant digital or transmetatarsal amputation; and group 2 patients were submitted to a guillotine-type below-knee amputation in view of ascending infection or extended necrosis that made below-knee amputation impracticable. The objective was to obtain healing of the stump at the below-knee level. Early results within 1 month of operation were as follows: 5 patients (3.3%) died of myocardial infarction. There was no graft sepsis, and groin wound sepsis occurred in 7 (4.5%). Of the group 1 patients 8 required major amputation (8.2%). Three patients in group 2 required proximal above-knee revision (14.3%). The overall limb or stump salvage rate within 1 month of surgery was 89.4%. It was possible to follow up 105 patients in group 1 and 18 in group 2 for between 2 years and 5 years. In group 1, 2.9% required major proximal amputation and 3.8% a subsequent femoral-to-distal bypass. In group 2 none required subsequent major proximal amputation. Overall in those available for long-term follow-up 97% retained the use of a salvaged limb or stump.(ABSTRACT TRUNCATED AT 250 WORDS)

Systemic complications after elective abdominal aortic surgery. A retrospective analysis.

While the range of systemic complications causing death after aortic surgery is well documented, the incidence is not. A study was undertaken to determine the incidence of systemic postoperative complications and the operative mortality of patients undergoing elective aortic surgery in a hospital that caters to a homogeneous population group. Records of 557 patients who had undergone aortic bypass or aneurysm replacement surgery over an 8-year period were studied at Addington Hospital, Durban. All had placement of a prosthetic fabric graft, 188 (33%) for aortic aneurysm replacement. Men made up 56% of the patients and the average age was 66 years. Standard selection criteria and peri-operative management were employed in all cases. All patients were classified according to the Goldman scoring system. There were significant systemic complications in 48 patients (8.6%), with 23 (4%) deaths. Respiratory complications were the most frequent (2.9%) followed by gastro-intestinal complications. (2.9%) followed by gastro-intestinal complications. The most frequent causes of death were cardiac arrest (20%) and gastro-intestinal malfunction, mainly bowel infarction. Only 3 patients developed acute renal failure in isolation but all died. When age was analysed as a factor in the causation of morbidity, there was an appreciably lower complication rate in patients under 50 years, but this reached a plateau in the 6th decade. The overall mortality and morbidity rates were acceptable. It would appear that age is weighted too heavily in the Goldman scoring system, although these criteria have reduced the incidence of cardiac complications.

Fibromuscular dysplasia of the external iliac artery in association with a congenital short leg and mesodermal malformation. A case report.

Fibromuscular dysplasia is an uncommon condition in general, and involvement of the external iliac artery is even rarer. It is a disease commonly seen in whites with a female preponderance. An unusual case--in that the patient was male and black, the site was unusual, and the associated abnormalities were unusual--is presented.

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.

Do pre-operative antibiotics reach the operative field in amputation surgery for peripheral vascular disease? A pilot study.

Amputation surgery in patients with peripheral vascular disease is associated with high revision and mortality rates. A prospective pilot study examined the intra-operative delivery of cefoxitin sodium to the amputation site, and used pre-operative transcutaneous oxygen pressure measurement to try to predict the tissue antibiotic levels at the amputation site. Antibiotic concentrations were measured in plasma and muscle from the amputation site at the time of amputation, and a significant difference in antibiotic distribution was found between healed and failed amputations. Transcutaneous oxygen pressures correlated with the antibiotic distribution.

Anastomotic aneurysm following aortobifemoral bypass.

OBJECTIVE: The aim of this study was to establish the incidence of anastomotic aneurysm following aortobifemoral bypass and to document management of this condition in our practice. DESIGN: This is a prospective study of anastomotic aneurysms developing in patients with aortobifemoral bypasses followed up for 49 months. SETTING: Two tertiary referral hospitals served by the Durban Metropolitan Vascular Service. PATIENTS: Four hundred and ninety-two patients underwent aortobifemoral bypass. Anastomotic aneurysms (N = 25) developed in 23 patients. Presence of anastomotic aneurysm was confirmed by Doppler ultrasound. INTERVENTIONS: All patients underwent aneurysm repair. RESULTS: Operations performed were: excision and interposition graft (15), re-suture (6), tube graft (1), crossover (1), graft-popliteal bypass (1) and ligation (1). There were no deaths and no recurrences. Wound infections occurred in 2 patients and occlusion of the opposite limb occurred in 1. CONCLUSION: Anastomotic aneurysms following aortobifemoral bypass are uncommon. They commonly occur as a result of anastomotic disruption. Management includes repair or excision, depending on the prevailing circumstances, and can be performed with good results.

Why we use the donor left kidney in live related transplantation.

UNLABELLED: In addition to the superior graft survival afforded by live related transplantation, this option has assumed an important role in the management of endstage renal failure in centres confronted with a scarcity of cadaveric kidneys. In pursuing this option, it is imperative that the donor has minimal morbidity. An ongoing dilemma is which side the kidney should be harvested from. This study reviews the anatomical basis for selecting the left kidney and the impact on outcome for patient and donor. A database comprising cadaveric and clinical subsets was analysed. The total sample size analysed was 1 244 kidney pairs (305 cadaveric; 939 clinical (61 live related left kidney transplants harvested by the extraperitoneal approach)). RESULTS: Additional renal arteries (ARAs): Right first, second = 18.6%, 4.7%; left first, second = 27.6%, 4.4%. Additional renal veins (ARV): Right first, second = 26%, 3.3%; left first only = 2.6%. Length of renal vein (cm): Right 2.4 +/- 0.7, left 5.9 +/- 1.5. Other venous variations encountered were on the left side only (renal collar 0.3%, retro-aortic vein 0.5%). In the live related transplant series 24.6% ARAs were encountered (first 19.7%, second 4.9%). The postoperative course and outcome of both donor and recipient were not associated with increased morbidity. While greater length of the left renal vein (LRV) afforded easier technical manipulation, it is interesting to note that its length is shorter than that reported in the literature. ARVs are infrequent on the left and when encountered the smaller calibre vessel may be ligated with impunity due to rich intrarenal anastomosis. In selecting the donor kidney the surgeon has to balance the prospect of fewer ARAs on the right against the benefit of a longer LRV. The solution to this dilemma can only arise from a randomised clinical study. In our practice, consistent use of the left kidney has not affected clinical outcome.

Descriptive retrospective analysis of the diagnostic yield and morbidity of four vessel catheter-directed cerebral angiography and multidetector computed tomographic angiography (MDCTA) performed at Inkosi Albert Luthuli Central Hospital (IALCH).

Imaging studies are indispensable in order to determine the source, location and pattern of intra and extra-axial brain haemorrhages. In our study of 277 patients carried out over an 18 month period, the most common reason of referral was subarachnoid haemorrhage followed by trauma. Aneurysms were the most common diagnosis (36%) with anterior and posterior communicating arteries being the most common locations. Fifty percent (50%) of patients investigated had a normal study. Our findings show that the yield from MDCTA and conventional angiography was relatively comparable, however, conventional angiography was superior in detection of aneurysms; hence, in cases were the MDCTA result was found to be normal despite a high index of suspicion for a subarachnoid haemorrhage, a follow-up MDCTA study or conventional angiography is useful. Moreover, conventional angiography was superior in detection of multiple aneurysms.