Distal arteriovenous fistula to maintain patency of the venous drainage of a latissimus dorsi flap following subclavian vein repair.

Successful reconstructive surgery with muscle flaps depends on adequate arterial supply and undisturbed venous drainage. Combining such surgery with reconstructive vascular surgery of a large-caliber vein that is responsible for the venous drainage of the flap poses an additional challenge--the repaired vein's susceptibility to thrombosis. Every attempt must be made to prevent venous outflow obstruction following muscle flap surgery. Data from the vascular surgery literature demonstrate a low success rate for subclavian vein repair. The success rate with venous reconstructive surgery has been greater when a distal arteriovenous fistula accompanied the repair. The present case described the use of a temporary distal cephalic-brachial arteriovenous fistula to maintain the patency of the venous drainage of a pedicled latissimus dorsi muscle flap, following subclavian vein repair, for one-stage coverage of a large chest wall defect.

Duplex scanning and CT angiography in the diagnosis of carotid artery occlusion: a prospective study.

OBJECTIVES: Differentiating total occlusion from tight stenosis of the internal carotid artery is crucial with regard to treatment and prognosis. At our institution, the diagnosis of carotid stenosis is based on duplex scanning. In cases of occlusion, duplex is not reliable, and angiography is performed, thereby increasing morbidity. We tried to determine whether a combination of duplex scanning and CT angiography (CTA) can replace angiography in the diagnosis of carotid occlusion. DESIGN: Prospective study. MATERIALS AND METHODS: From 1995 to 1997, 148 patients were diagnosed as having carotid occlusion by duplex scanning. CTA was performed on all patients. Forty-four patients underwent angiography and 10 patients were surgically explored. Both procedures were considered "gold standard" for the diagnosis of occlusion. RESULTS: Arteries found to be occluded by both CTA and duplex scan were confirmed as occluded by angiography or operation in 95% of the cases (42/44). Arteries found to be occluded by duplex but patent by CTA were confirmed as patent in 100% of cases (10/10). CTA has a significantly higher positive predicting value for diagnosing occlusion than duplex scan (95% vs. 77%, p value < 0.01). CONCLUSIONS: Combination of duplex scanning and CTA is safe and accurate in the diagnosis of carotid occlusion and can replace angiography in most cases, thereby reducing morbidity.

Appendiceal calculi and fecaliths as indications for appendectomy.

This study was done to determine the association between appendiceal fecaliths or appendiceal calculi and the presence of acute appendicitis. We retrospectively reviewed the medical records of all patients from 1977 through 1986 who underwent appendectomy for a clinical diagnosis of acute appendicitis (group 1, 2,331 patients) or who underwent appendectomy either incidentally or during colectomy for nonappendiceal pathologic factors (group 2, 1,066 patients). Fecaliths were six times more common than calculi, but calculi were more often associated with perforated appendicitis or periappendiceal abscess (45 per cent) than were fecaliths (19 per cent). Appendiceal fecaliths and calculi appear to play a role in the pathogenesis of acute appendicitis and are associated with complicated appendicitis (perforation and abscess). Appendectomy should be considered for patients in whom an appendiceal calculus is recognized incidentally.

Abdominal aortic aneurysm and aortic occlusive disease: a comparison of risk factors and inflammatory response.

OBJECTIVE: to compare patients with abdominal aortic aneurysm (AAA) and aortic occlusive disease (AOD) with regard to risk factors for atherosclerosis, co-morbid conditions and inflammatory activity. PATIENTS AND METHODS: a total of 155 patients undergoing abdominal aortic surgery between January 1993 and October 1997: 82 (53%) had aneurysmal disease and 73 (47%) had occlusive disease. Principal risk factors were compared: age; gender; smoking; hypertension; hyperlipidaemia; diabetes mellitus; severe peripheral vascular disease (PVD) and ischaemic heart disease. Aortic wall tissue samples were obtained during surgery. A prospective blind analysis was performed for the presence of inflammatory cytokines TNF-alpha, IL-1 beta, IL-6 and TGF-beta. RESULTS: the average age of AAA patients was 74 years (50-88), while that of AOD patients was 61 years (43-82) (p<0.0001). Diabetes mellitus was found to be much more prevalent in the AOD group (p<0.001), while hypertension and severe PVD were more prevalent in the AAA group (p<0.001). No differences were found concerning any of the risk factors. Inflammatory cytokine activity: AAA tissue samples contained significantly higher mean TNF-alpha and IL-6 levels compared to the AOD samples (5.6+/-2.7 x 10 E-4 vs. 4.4+/-2.7 x 10 E-5 atmoles/microl (p=0. 01), and 0.6+/-0.4 vs. 0.01+/-0.006 atmoles/microl (p=0.02) respectively). No differences were found related to IL-1 beta and TGF-beta. CONCLUSIONS: (1) Patients with AAA have fewer atherosclerotic risk factors than do patients with AOD. (2) Patients with AAA and AOD have significantly different inflammatory activity. (3) The data supports the hypothesis that AAA and AOD are probably two different pathological entities.

Neck irradiation: a risk factor for occlusive carotid artery disease.

OBJECTIVES: to determine whether irradiation is an independent risk factor for carotid atherosclerosis, and propose guidelines for patient follow-up. DESIGN: a retrospective case control study. MATERIALS AND METHODS: two groups of patients with severe carotid artery stenosis (>70%) were compared: 30 post-neck irradiation patients, and a control group of 100 patients with no history of neck irradiation. Disease location and severity were assessed by duplex. The relationship between atherosclerotic risk factors, time since irradiation and carotid artery disease was examined. RESULTS: the average age of study group patients was 67 years (43-86) compared to 69 years (46-89) in the control group. The average interval from irradiation to diagnosis was 14 years (3-53) (median 12.5 years). The study group suffered less from diabetes, ischaemic heart disease, and peripheral vascular disease ( p<0.02). There were no significant differences among risk factors with respect to age, gender, smoking, hypertension, and hypercholesterolemia. Post-neck irradiation patients had a significantly higher prevalence of bilateral disease (p=0.02), and a higher rate of common carotid artery lesions (p<0.002). CONCLUSIONS: neck irradiation should be considered a risk factor for occlusive carotid artery disease. Preoperative angiographic study should be considered, due to frequent involvement of the common carotid artery.

Correlations of dose and time-dose-fractionation factors (TDF) with treatment results and side effects in cancer of the uterine cervix.

Treatment results and side effects were analyzed for 57 patients with stage IB-IIIA cancer of the uterine cervix who received external beam radiotherapy combined with intracavitary insertion of cesium-137 sources. The total dosage and time-dose-fractionation (TDF) factors were calculated at point A and at points of maximum exposure in the rectum and bladder. The overall 5-year survival was 62%, and 78% of the complete responders were free of disease at 5 years. A total of 12 patients (21%) developed rectal complications. Two patients (4%) had rectal fibrosis and proctitis; seven cases of rectal bleeding occurred (12%), and 3 patients (5%) developed rectovaginal fistulas. There was no correlation between dose and TDF at point A and treatment failure or appearance of rectal complications. However, the occurrence of radiation damage in the rectum was consistently associated with high values of TDF when they were calculated in the region of maximal exposure in the rectum. The results suggest that TDF may be a useful parameter for predicting radiation damage in combined external beam and intracavitary treatment of cervical cancer.

Seatbelt injury to the common iliac artery: report of two cases and review of the literature.

Blunt trauma to the common iliac artery is rather rare. Moreover, seatbelt injuries to the common iliac artery have not yet been reported. This article presents two cases of seatbelt injury involving the common iliac artery. A deceleration-type mechanism is suggested as the primary cause of injury, resulting in the production of an intimal flap. The diagnosis of such an injury is based on clinical suspicion, a change of pulse, or lower limb ischemia. On arteriotomy the damage is greater than seen on external examination. Once diagnosed prompt treatment should follow to prevent loss of life or limb. The signs, symptoms, and modalities of treatment are reported, as well as a review of the literature.

Carotid endarterectomy in awake patients with contralateral carotid artery occlusion.

OBJECTIVES: Patients with severe stenosis of an internal carotid artery with contralateral occlusion (ICO) are at an increased risk for stroke, and therefore surgical treatment is usually recommended. Carotid endarterectomy (CEA) under regional anesthesia enables constant monitoring of neurologic status and selective shunting in cases of clinically evident cerebral ischemia. In this study, we assess the selective use of shunts based solely on changes in neurological status in awake patients with ICO undergoing CEA as well as their complication rates. METHODS: During 1996-1998, we studied intraoperative findings and results of CEA under regional anesthesia with clinical monitoring of neurological status in two groups: (1) patients with stenosis (> 70% by NASCET) and contralateral occlusion (n = 50) and (2) patients with stenosis and no contralateral occlusion (n = 94). RESULTS: Shunt insertion was required in 42% of group 1, and 6% in group 2. All of the patients in group 1 requiring shunts had stump pressures < 50 torr. The average stump pressure of group 1(40 torr) was significantly lower than that of group 2 (75 torr), and was also lower than that of patients with severe contralateral stenosis (35 patients, 76 torr). Perioperative stroke rates were identical in both groups (2.1%). CONCLUSION: Since ICO patients are at a high risk for brain ischemia during ICA clamping, they require shunt insertion frequently. Patients with no contralateral occlusion require shunting at a much lower rate - even in the presence of severe contralateral stenosis. Regional anesthesia allows for early detection of brain ischemia and therefore, the perioperative results in both groups are similar.

Long-term perfusion of the cerebroventricular system of dogs without leakage to the peripheral circulation.

Methods developed previously for studying the effect of cerebroventricular injection or ventriculocisternal perfusion of test substances are unsatisfactory because the test substance is not confined to the central compartment. Most likely the test substance enters the peripheral circulation via the arachnoid villi. The purpose of this paper is to describe a method for perfusing the cerebroventricular system of conscious dogs without passage of test substances to the peripheral circulation. With the method described, the mean (+/- SE) cerebroventricular pressure in conscious dogs was 7.4 +/- 0.8 cmH2O (n = 16), and the mean (+/- SE) production of cerebrospinal fluid (CSF) was 25 +/- 0.3 microliter/min (n = 16). Endogenously occurring migrating myoelectric complexes (MMCs) of the small intestine were recorded in dogs before catheters were implanted in the left and right lateral ventricles and the fourth ventricle and after catheter implantation during cerebroventricular perfusion with artificial CSF alone or with CSF containing sulfated (S-CCK-OP) or nonsulfated cholecystokinin octapeptide (NS-CCK-OP). Only cerebroventricular perfusion with S-CCK-OP (1.2 pmol.kg-1.min-1; n = 20) replaced spontaneously occurring MMCs with a fed-like pattern of myoelectric activity. The results suggest that replacement of the fasting pattern of myoelectric activity with a fed-like pattern in the fasted dog was mediated by CCK-A receptors located in one or more brain nuclei surrounding the third ventricle.