Arterial clamping leads to stenosis at clamp sites after femoropopliteal bypass surgery.

BACKGROUND: To date, the incidence and clinical relevance of arterial stenosis at clamp sites after femoropopliteal bypass surgery is unknown. METHODS: Ninety-four patients underwent a femoropopliteal bypass in which the arterial inflow and outflow clamp sites were controlled by the Fogarty-Soft-Inlay clamp and marked with an hemoclip. The number of pre-existing atherosclerotic segments, clamp force, and clamp time were recorded and the occurrence of a stenosis at the clamp site was determined. RESULTS: After a mean follow-up of 83 months, a significant stenosis was confirmed at 23 of the 178 clamp sites (12.9%; 95% confidence interval 8.4 to 18.8). The mean number of pre-existing atherosclerotic segments (P = .28) and the mean clamp force (P = .55) was similar between the groups with and without a stenosis. There was a significant difference regarding clamp time between the group with and without a stenosis (38 minutes and 26 minutes, P = .001). CONCLUSION: Arterial clamping, even with the Fogarty-Soft-Inlay clamp, can lead to clamp stenosis and seems to be related to the duration of clamping, but not to pre-existent atherosclerotic burden.

A young man with intimomedial mucoid degeneration of the brachial artery.

Intimomedial mucoid degeneration is a rare disorder and has been described as a distinctly different entity from Erdheim's cystic medial necrosis. Most studies show a strong predominance in African American females with hypertension. In our case report, we describe the presence of a large brachial aneurysm in a young white male with intimomedial mucoid degeneration.

Evaluation of 4-mm to 7-mm versus 6-mm prosthetic brachial-antecubital forearm loop access for hemodialysis: results of a randomized multicenter clinical trial.

OBJECTIVE: Prosthetic arteriovenous fistulas for hemodialysis vascular access have a high incidence rate of thrombotic occlusions that result in graft failure. This randomized multicenter study was performed to assess the patency rates and the effect of 4-mm to 7-mm grafts on the development of stenoses. METHODS: A total of 109 patients who needed vascular access for hemodialysis were randomized to receive either 6-mm (n = 57) or 4-mm to 7-mm prosthetic brachial-antecubital forearm loop accesses (polytetrafluoroethylene). Duplex scanning, with measurement of blood flow and peak systolic velocity and detection of stenoses (>50%), was performed at 1, 6, and 12 months after surgery. Clinical data were obtained in a prospective manner and primary, assisted primary, and secondary patency rates were calculated with the Kaplan-Meier life-table analysis. Statistical analysis was performed with the independent samples t test and chi(2) test. RESULTS: At 1 year, patency rates were similar for both 4-mm to 7-mm and 6-mm prostheses (primary, 46% versus 43%; assisted primary, 62% versus 58%; secondary, 87% versus 91%). The incidence rate of thrombotic occlusion was comparable for both groups (0.74/patient-year versus 0.88/patient-year; P >.05). Mean graft flow at 1, 6, and 12 months was 1416 versus 1415 mL/min, 1345 versus 1319 mL/min, and 1595 versus 1265 mL/min (P >.05) for 4-mm to 7-mm and 6-mm grafts, respectively. Also, no differences in peak systolic velocities in any part of the grafts were observed. The percentage of stenoses detected was equal in both groups at 1 year after surgery (27% versus 20%; P >.05). CONCLUSION: A 4-mm to 7-mm tapered prosthetic brachial-antecubital forearm loop access did not reduce the incidence rates of stenoses and thrombotic occlusions compared with a 6-mm prosthetic conduit. Moreover, no differences in patency rates were observed. Therefore, we believe that the 4-mm to 7-mm graft should not be used routinely for hemodialysis vascular access.

Synchronous tumours of the unilateral parotid gland: rare or undetected?

INTRODUCTION: Multiple tumours of the parotid gland with the same histological appearance may occur as synchronous unilateral tumours, but bilaterality has also been reported. Synchronous multiple unilateral parotid tumours with different histology remain rare. METHODS: Between January 1988 and May 2002, a total of 341 patients underwent parotidectomy in our department. Medical charts were reviewed retrospectively for synchronous multiple unilateral tumours. RESULTS: Fourteen patients had two or more tumours within the same specimen. The combinations encountered were two to four adenolymphomas (n=9), adenolymphoma plus pleomorphic adenoma (n=3), adenolymphoma plus MALT lymphoma (n=1), and pleomorphic adenoma plus acinic cell carcinoma (n=1). The outcome was clinical freedom from signs of tumour recurrence in any patient (mean follow-up = 51 months). CONCLUSION: Synchronous multiple unilateral parotid tumours usually include two or more adenolymphomas and might occur more often than previously realized. The possibility of a concomitant carcinoma, and the prevention of recurrent tumours, may warrant a more radical surgical excision of the parotid gland, accurate intraoperative examination of the resected specimen, and routine histological evaluation of the entire specimen. Preoperative radiological investigation may further increase the chances of finding multiple parotid tumours.

Partial matrix excision or segmental phenolization for ingrowing toenails.

OBJECTIVE: To decide whether partial nail extraction with phenolisation or with partial excision of the matrix should be the standard treatment in patients with ingrowing toenails of the hallux. DESIGN: Randomized clinical trial with 12-month follow-up evaluations performed by observers who did not know which procedure was applied. SETTING: Outpatient department of a surgical teaching hospital. PATIENTS: Fifty-eight consecutive patients with a total of 63 ingrowing toenails were randomized. INTERVENTION: Thirty-four partial matrix excisions ("matrix" group) and 29 phenolizations ("phenol" group) were performed. MAIN OUTCOME MEASURES: Recurrence rate, postoperative morbidity (pain, wound exudates, and scar discomfort), and time to complete recovery (wearing shoes, performing normal activities/work). RESULTS: Recurrences were seen after 7 procedures in the matrix group and also after 7 procedures in the phenol group, of which patients were symptomatic and required a second operation in 4 and 3 instances, respectively. None of the observed differences in wound healing, postoperative pain, and recovery were statistically significant. CONCLUSIONS: Partial matrix excision and phenolization are equally effective in treating ingrowing toenails. Because the use of the toxic agent phenol should be avoided, partial matrix excision is the preferable procedure. But in view of the high recurrence rate, there is a need for further improvement of the treatment of ingrowing toenails.