Pseudoaneurysm Development after Drug-Eluting Balloon (DEB) Angioplasty of a Venous Femoropopliteal Bypass Graft.

Endovascular recanalization of occluded venous femoropopliteal bypass grafts is widely used because of easy access. This case report describes pseudoaneurysm developing 4 weeks after endovascular recanalization of an occluded in situ venous femoropopliteal graft. The patient was treated for a popliteal aneurysm with a venous femoropopliteal bypass graft, which subsequently occluded. Four weeks after DEB PTA, the occluded graft developed 3 pseudoaneurysms. Impaired vessel wall healing after intraluminal paclitaxel administration could have contributed to this. This case adds a perspective to the choice of treatment of occluded venous femoropopliteal bypass grafts.

Wound contamination in cardiac surgery. A systematic quantitative and qualitative study of the bacterial growth in sternal wounds in cardiac surgery patients.

OBJECTIVES: To investigate the degree of bacterial contamination in the sternal wound during cardiac surgery and the sternal skin flora after operation in order to increase our understanding of the pathogenesis of sternal wound infections. DESIGN: Prospective study where cultures were taken peri- and postoperatively from sternal wounds and skin. SETTING: University Hospital. PATIENTS: 201 cardiac surgery patients. RESULTS: 89% of the patients grew bacteria from the subcutaneous sternal tissue. 98% of the patients showed bacterial growth on the surrounding skin at the end of the operation. We found both commensal and nosocomial bacteria in the sternal wound. These bacteria had different temporal distribution patterns. Coagulase-negative staphylococci (CoNS) and Propionibacterium acnes (PA) were by far the most prevalent bacteria during and after the operation. Furthermore, 41% of patients had more than 10,000 CFU/pad CoNS on the skin. There was no correlation between length of operation and number of bacteria. Men displayed higher bacterial counts than women on the skin. CONCLUSION: Skin preparation with ethanol/chlorhexidine is unable to suppress the physiological skin flora for the duration of a heart operation. A decrease of CoNS and PA postoperatively can be caused by competitive recolonisation of commensal and nosocomial bacteria.

Open surgical treatment for postthrombotic syndrome.

The postthrombotic syndrome counts as a frequent long-term complication after deep vein thrombosis with approximately 20%-50% of affected patients after deep vein thrombosis. The earliest that diagnosis of postthrombotic syndrome can be made is 6 months after deep vein thrombosis. Most patients suffer from swelling and chronic pain. In all, 5%-10% of patients may even develop venous ulcers. The complex etiology consists of limited venous drainage because of chronic occlusions and secondary insufficiencies of venous valves inducing non-physiological venous reflux. Conservative management, first of all compression therapy, is of crucial importance in treatment of postthrombotic syndrome. Endovascular and open surgical techniques can additionally be used in a small subgroup of patients. Although rarely performed, this article illuminates the open surgical techniques in treatment of postthrombotic syndrome such as venous bypass surgery, valve repair and varicose vein surgery.

Antibiotic Prophylaxis With Trimethoprim/Sulfamethoxazole Instead of Cloxacillin Fails to Improve Inguinal Surgical Site Infection Rate After Vascular Surgery.

BACKGROUND: Surgical site infections (SSIs) and their prevention continue to be a major point of focus in all surgical specialties today. Antibiotic prophylaxis is one of the mainstays in their prevention. Due to the consistently high proportion of infections caused by intestinal flora from the start of our wound surveillance registry in 2005, we conducted a change in prophylactic antibiotic therapy from cloxacillin in 2012 to trimethoprim/sulfamethoxazole (TMP-SMX) in 2013. METHODS: The study included all patients undergoing vascular surgery with groin incisions between March 1 and June 30 in 2012 and 2013, respectively, whereby the antibiotic regime was changed in between the 2 sampling periods. The diagnosis of SSI was based on clinical examination and microbiological results. RESULTS: Two hundred nineteen patients with inguinal incisions were included in the analysis: 105 in the cloxacillin group of which 19% had SSI and 114 in the TMP-SMX group with an SSI rate of 18% (P = .77), without differences between the 2 groups regarding age, gender, proportion of emergency surgery, type of surgery, or frequency of concomitant foot ulcers. The high proportion of infections caused by intestinal flora between time periods was unchanged (67% vs 81%, P = .34). CONCLUSION: There was no difference between the 2 groups, suggesting that the choice of antibiotic prophylaxis had a limited role in preventing SSI at our center. Despite this, the lower cost and ease of the administration of TMP-SMX can be seen as convincing advantages.

Is increased thrombin activation in patients with abdominal aortic aneurysms dependent on area or volume of aneurysm thrombus mass?

OBJECTIVES: Does thrombin activation seen in patients with abdominal aortic aneurysms (AAA) relate to the thrombus surface area or volume within the aneurysm? PATIENTS AND METHODS: A total of 130 patients with AAA were analyzed regarding levels of the complex between activated protein C-protein C inhibitor (APC-PCI) and AAA morphology. Analysis of APC-PCI complex was made using a sandwich immunofluorometric method. RESULTS: Increased APC-PCI concentrations were seen in patients with AAA (0.44 microg/L; P < .001 compared with controls). The correlations of APC-PCI values were r = .13, P = .13 for aneurysm size, r = .08, P = .35 for thrombus surface area, and r = .13, P = .14 for thrombus volume. APC-PCI values elevated to 0.45 microg/L in 10 patients with AAA having no or very little thrombus mass. CONCLUSION: Disappointingly, no correlation was found between thrombus surface area or volume and levels of the APC-PCI complex. Mechanisms other than the AAA-sac thrombus must be evaluated as cause of thrombin activation in patients with AAA.

Endovascular treatment of venous occlusive disease.

Endovascular treatment of acute and chronic iliac vein occlusions has proven to be safe and effective. Recanalization of chronic occlusions with balloon angioplasty and stenting can re-establish normal venous flow in the iliac veins and the IVC and relieve symptoms in the majority of treated patients. CDT with recanalization and stenting of underlying chronically obstructed iliofemoral segments is becoming the treatment of choice for patients with acute iliofemoral thrombosis, as anticoagulation and compression therapy alone are not satisfactory in preventing PTS. The new treatment modalities offer stimulating options for a patient group that is not adequately treated, neither by medical nor open surgical therapy. The substantial effort and additional costs of endovascular treatment appear to be justified by the encouraging mid-term results both for patients with acute and chronic occlusive iliofemoral disease. However, multi-center randomized prospective studies are required to further validate the role of these techniques.

Rupture of a synthetic VSD patch 28 years after total correction of Fallot's anomaly.

Patients operated on for complex congenital heart malformations need continuous follow-up. We present a male patient born in 1948 with Fallot's anomaly. A total correction was performed when he was 21 years old. Twenty-eight years after the operation, at routine follow-up, he presented with a significant left-to-right shunt because of a new ventricular septal defect. During the operation we found the original patch to be fractured with a central perforation. The patient received a new patch and has been without any clinical symptoms since.