Repair of arterial injury after blunt trauma in the upper extremity - immediate and long-term outcome.

OBJECTIVE: In contrast to upper extremity stab and gunshot wounds, data on management and outcome in blunt trauma (BT) are limited by small numbers and short follow-up periods. METHODS: This study is a retrospective data analysis. All patients who had undergone arterial repair after upper-limb BT were included. Exclusion criteria were artery ligation and/or primary limb amputation. Endpoints included the following: peri-operative death, limb salvage, primary and secondary patency, vascular re-operation and/or intervention. RESULTS: Eighty-nine patients (71 male; median age: 34.6 years, range: 2.5-81.7) underwent reconstruction of 96 arteries after BT since 1989: subclavian (n=16), axillary (n=22), brachial (n=48) and forearm (n=10). Concomitant arm vein lesions were present in 15 patients (17%) and accompanying nerve (n=38; 43%) and/or orthopaedic injuries (n=64; 72%) in 77 patients (87%). The 30-day mortality rate was 2% with the limb-salvage rate being 98%. Six reconstructions occluded during the first week (primary/secondary patency rate: 93%/99%). After a median follow-up time of 5.1 years, 67% of the patients were followed: There were no secondary amputations and no arterial re-interventions. CONCLUSIONS: Arterial repair in upper extremity BT has excellent early and long-term outcome. In contrast to a significant risk of early occlusion, limb loss after repair, late vascular re-intervention and late arterial occlusion or stenosis are rare.

Using a weight-of-evidence approach for management of watersheds.

This research used a weight-of-evidence approach to evaluate sources of contaminants in a drinking water watershed that serves as part of the City of Boston's water supply. The approach incorporated land use analysis using GIS, sanitary surveys, traditional water quality monitoring and microbial source tracking (MST) tools. Case-study tributaries were selected based on elevated faecal coliform counts. Land use analysis and sanitary surveys were used to identify suspected microbial sources, including residential septic systems, agricultural animal operations, commercial/industrial operations and wildlife activity. Sampling sites were selected to hydrologically isolate potential contamination sources. Samples were collected seasonally over 1 year and analysed for traditional and MST parameters. Results demonstrated that both septic systems and a horse stable were contributing microbial loads in the first tributary. In the second tributary, septic systems from the townhouses were contributing microbial loads while a plant nursery was contributing organic matter. This evidence was used to evaluate best management practices to mitigate the contamination.

Mid-term results after endovascular repair of the atherosclerotic descending thoracic aortic aneurysm.

INTRODUCTION: Thoracic aortic aneurysms (TAA) are the most common condition of the thoracic aorta requiring surgical treatment. Despite significant improvement in anesthetic, surgical techniques and postoperative care, the mortality and morbidity rate in TAA-repair remains high. The aim of this study was to assess the morbidity and mortality rate after endovascular stent-graft treatment of atherosclerotic (non-dissecting) TAAs. METHODS: Thirty-one patients, ASA-classification III-IV, with symptomatic or expanding atherosclerotic TAAs underwent endovascular stent-graft repair between May 1997 and August 2003. Procedures were performed on an emergency basis in 13 patients and elective in 18 patients. Patients were assessed postoperatively by routine CT-scan within 48 h. Further follow up investigations were performed after 3, 6, 12 months and annually thereafter. RESULTS: Stent-graft placement was successful in all but one patient in whom the stent-graft procedure had to be postponed due severe hemodynamic instability. Perioperative mortality rate was 19% including three haemorrhages, two cardiac events and one respiratory failure (6/31). Technical success rate was 55% (17/31). Completion CT scans performed in 30 patients within 2 days of stent-graft procedure showed type I leaks in seven patients (23%), type II leaks in four patients (13%) and type III leaks in two patients (6%). Further complications included one stroke, one paralysis, one spinalis anterior syndrome and five relevant access related complications. New onset endoleaks, all type I, were observed in seven patients (23%) occurring after 3, 4, 7, 8, 17, 25 and 26 months. Mean follow-up was 15 months (range 2-69 months). CONCLUSION: Thoracic aortic atherosclerotic aneurysm stent-grafting is feasible but not without significant morbidity and mortality.

Traumatic pseudoaneurysm of the brachiocephalic artery following medianoscopy: initial endovascular repair followed by open surgery--a case report.

Endovascular stent graft repair of traumatic vessel injuries is gaining worldwide acceptance as a minimally invasive alternative to open surgical repair. However, effective endovascular repair fails if the aneurysm is not completely excluded. Conversion to open surgery may be unavoidable in such cases. Herein we describe the case of a 45-year-old man who was referred to our hospital with a pseudoaneurysm of the proximal brachiocephalic artery caused by biopsy during diagnostic medianoscopy. The pseudoaneurysm was primarily treated by stent-graft implantation into the proximal brachiocephalic artery. As a result of the unfavorable location of the lesion exclusion of the aneurysm failed and the initial therapy had to be extended to open reconstruction of the brachiocephalic artery. A bypass procedure from the aortic arch to the right common carotid artery was performed with reinsertion of the right subclavian artery to exclude the pseudoaneurysm.

[Effectiveness of locoregional rt-PA lysis in acute leg and arm vein thrombosis]. / Wirksamkeit der loko-regionalen rt-PA-Lyse bei Bein- bzw. Armvenenthrombose.

39 patients suffering from a thrombosis of the peripheral venous system were treated with a loco-regional lysis, using rt-PA. Two cycles of 40 mg rt-PA a day were applicated by means of a special drainage-management, using perforans veins. During lytic therapy, 20,000 to 30,000 IE of unfractionized heparin were additionally administered. Laboratory work including aPTT and fibrinogen measurement was performed every 8 hours. Additionally a phlebography was performed after 24 hours. Patients received an anticoagulative therapy using sintrom or marcumar the following 3 months. We obtained a successful thrombolysis without any major complications in 90%. Minor complications included 3 peripheral pulmonary embolisms. Duplex sonographic and plethysmographic follow up was performed in 25 patients one year after operation. In two patients with ankle edema insufficient valves at the popliteal vein were found with both diagnostic modalities. 23 patients showed no signs of insufficient valves neither clinically nor at duplex sonography and plethysmography. The locoregional lysis appears to be an effective method for the treatment of acute peripheral vein thrombosis.

Ruptured false abdominal aortic aneurysm during pregnancy: Caesarean delivery followed by aortic reconstruction.

We describe a case of a successfully treated ruptured abdominal aortic aneurysm during pregnancy. The importance of close clinical follow-up after any aortic reconstructions is highlighted.

[Indirect traumatic diaphragmatic rupture]. / Zur Problematik der traumatischen indirekten Zwerchfellruptur.

Between 1969 and 1988 51 polytraumatized patients were treated for rupture of the diaphragm due to blunt trauma. In 39 cases the lesion was in the left hemidiaphragm, in 11 cases on the right side and in one case on both sides. Clinical investigation and posterior-anterior chest X-ray were the most important diagnostic procedures. A high percentage of ruptures was only detected intraoperatively during acute laparotomy/thoracotomy. Early or delayed surgery had no influence on the survival of patients. The prognosis depends on the severity of associated injuries, which are the main causes of death in these patients.

Isolated iliac artery aneurysms.

Clinical and diagnostic data were collected from 22 men with iliac artery aneurysms treated surgically over a period of 22 years. Their ages ranged from 47 to 80 years (mean 64.0). Eight patients had multiple aneurysms. Thirty isolated iliac artery aneurysms were detected, 20 aneurysms (66.6%) located on the right and 10 (33.3%) on the left side. Twenty-six aneurysms were found in the common iliac artery (86.6%). Fifteen patients were symptomatic (68.2%); rupture occurred in five patients (22.7%), three of whom were initially asymptomatic. Thirteen of 17 patients whose aneurysms did not rupture had a palpable mass (76.4%), and three had bruits in the area of the aneurysm. All 22 patients were subjected to operative procedures. Seventeen patients operated upon electively survived, whereas only three patients who were operated upon after rupture survived. Graft interposition was the most common procedure. All 20 patients who survived after the operation were followed. Two died of myocardial infarction three and five years later, one of cancer six years later, and one of an unknown cause eight years after operation. Iliac artery aneurysms are extremely rare; their diagnosis is very difficult. The mortality rate is two times higher than in aortic aneurysms, once the diagnosis has been established. Therefore elective resection and arterial reconstruction are recommended.

[Gastro-pericardial fistula following transthoracic fundoplication]. / Gastro-perikardiale Fistel nach transthorakaler Fundoplikatio.

A gastro-pericardial fistula is a rare complication following repair of a hiatus hernia. Only prompt diagnosis and treatment may prevent the fatal outcome of this condition.