Abdominal compartment syndrome after mesenteric revascularization.

Abdominal compartment syndrome (ACS) results from increased pressure within the abdominal cavity leading to multisystem organ dysfunction. The most common cause of ACS is increased intraperitoneal volume from any source, but extrinsic compression can also cause increased intra-abdominal pressure. Although ACS has been well described in patients with trauma, little has been reported on ACS in postoperative patients without traumatic injuries. We report on a patient who had acute ACS 2 days after surgical revascularization for chronic mesenteric ischemia. With appropriate treatment, the patient made a rapid and complete recovery. We present this case of acute ACS in the postoperative patient without trauma to increase awareness and help minimize death caused by this devastating syndrome.

Risk neutralization in cardiac operations: detection and treatment of associated carotid disease.

BACKGROUND: A screening and treatment protocol was implemented to extend the benefit of prophylactic carotid endarterectomy to patients who had open heart operations. METHODS: Patients aged 65 or older or who at any age had left main coronary disease, transient ischemic attack, or stroke were eligible for preoperative carotid duplex screening. Carotid endarterectomies and open heart operations were planned as a staged (n = 59) or combined procedure (n = 55) for angiographically confirmed carotid stenosis of at least 80%. RESULTS: Duplex scans were obtained in 1,719 of 7,035 open heart surgical patients over 8 years. The overall stroke rate was 1.5% (108 of 7,035). Seven of these were strokes of carotid origin (0.1%). There were 129 patients with at least 80% stenosis. One hundred fourteen had carotid endarterectomy preceding open heart operation, and none had carotid artery stroke. Twelve patients with at least 80% carotid stenosis by duplex scan had open heart operations without prophylactic carotid endarterectomies. There were four carotid strokes in these 12 patients (p = 0.0001; odds ratio, 20.2). Stroke risk remained significantly elevated (16.8%, p = 0.005) in the 50% to 79% group. The changes associated with the reduced risk afforded by this screening and treatment strategy amounted to $346 for each patient in the study. CONCLUSIONS: The risk of carotid stroke at the time of cardiac operation can be defined by duplex screening. Prophylactic carotid endarterectomy neutralizes the risk in those with at least 80% stenosis. Consideration for lowering the threshold for assessment and treatment of carotid stenoses appears warranted. The economic investment is recouped by the savings in system resources that would have been depleted through care for carotid stroke and its sequelae.

Vena caval interruption.

While anticoagulation remains the treatment of choice for acute pulmonary thromboembolism, vena caval interruption represents an alternative for persons with either a contraindication to or a complication of anticoagulation. The authors retrospectively reviewed their experience with vena caval interruption over a recent 5-year period. One hundred seven Greenfield filters (Medi-Tech; Watertown, MA) and 13 external vena caval clips were used in 120 patients. Indications for caval interruption were: 1) contraindication to anticoagulation (38%), 2) recurrent pulmonary embolism despite adequate anticoagulation (23%), 3) prophylaxis (22%), and 4) complications associated with anticoagulation (17%). Vena caval interruption was successfully accomplished in 98 per cent of attempts. The overall complication rate was 7 per cent, with no procedure-related major morbidity or mortality. Sixty-five patients were followed for a mean of 36 months. In that interval, there were the following: 1) one instance of venous stasis ulceration, 2) two cases of late caval thrombosis, and 3) one person with documented recurrent pulmonary emboli. Significant edema requiring support stockings was reported in 16 per cent of persons with Greenfield filters and 37 per cent of those with caval clips. Vena caval interruption by use of the Greenfield filter is a safe and effective means of protecting against pulmonary embolism with few immediate or long-term complications.

Rupture of a previously bypassed popliteal aneurysm: a case report.

A case of rupture of a previously excluded popliteal aneurysm is reported and the pertinent literature reviewed. Symptoms of aneurysm expansion with nerve compression preceded the rupture. The need for continued follow-up after treatment of popliteal aneurysms is emphasized.

Intra-arterial thrombolysis for acute limb ischemia: a three-year experience.

Peripheral arterial thromboembolism and thrombosis of arterial grafts continue to threaten viability of extremities. Percutaneous intra-arterial thrombolysis (IAT) and angiodilatation have afforded limb salvage in some of these patients. Proper patient selection appears to be the hallmark of success with IAT. During a recent three-year period, we used IAT in 32 extremities in 28 patients who had acute arterial insufficiency. Before IAT, 16 extremities were painful at rest, and 16 had incapacitating claudication. The overall success rate was 38%, but some degree of thrombolysis occurred in 88%. Limb salvage was achieved in 27 of 32 extremities (84%). Only five of 17 limbs (29%) with arterial graft thrombosis required no operation or an operation of lesser magnitude than predicted before IAT. Of six extremities with native arterial embolism, four (67%) were completely cleared with IAT. Major complications occurred in eight cases (25%), with two IAT-related deaths (6%). This study suggests that IAT is best reserved for individuals with acute limb ischemia caused by arterial embolus, those whose degree of ischemia would tolerate a 24-hour trial of IAT, and those whose femoral or tibial runoff is not likely to require remedial operation.

Transcatheter carotid occlusion: an alternative to the surgical treatment of cervical carotid aneurysms.

The treatment of choice for various aneurysms of the common and internal carotid arteries may involve carotid artery occlusion rather than a reconstructive approach. Carotid occlusion may be accomplished either surgically or via an endovascular method. We present two cases of patients with cervical carotid artery aneurysms in which the endovascular method was used for carotid occlusion, describe our rationale for using this approach rather than surgical intervention, and discuss the role of this method of treatment for this condition.

Venous gangrene associated with heparin-induced thrombocytopenia.

We present a patient with deep venous thrombosis, which progressed to venous gangrene while the patient was receiving heparin therapy. Heparin-induced thrombocytopenia was confirmed with platelet aggregation studies, and a causal relationship is suspected. The association is an argument for close monitoring of platelet counts in patients undergoing heparinization for deep venous thrombosis.