Rescue of an axillary-axillary arteriovenous graft not amenable to endovascular intervention by formation of an axillary loop: a case report.

Central venous obstruction associated with a distal arteriovenous fistula can result in massive swelling of the affected extremity and venous hypertension. We present the surgical rescue of an axillary-axillary arteriovenous access ((necklace graft) between the left axillary artery to the contralateral axillary vein), compromised by central venous stenosis, by conversion into an arteriovenous axillary loop graft (AVALG) as an additional 'exotic' grafting procedure in the anterior chest. This procedure resulted in the salvage of the patient's access and rapid resolution of the associated upper extremity swelling.

Randomized clinical trial comparing decellularized bovine ureter with expanded polytetrafluoroethylene for vascular access.

BACKGROUND: The SynerGraft model 100 (SG 100) is a decellularized bovine uereter graft developed to improve on prosthetic conduits for vascular access. Its clinical performance was compared with polytetrafluoroethylene (ePTFE) in a prospective, pilot randomized study. METHODS: Patients requiring haemodialysis with no native vein options were included. Between June 2004 and June 2007, 29 patients received SG 100 and 27 ePTFE grafts. Forty-five patients had undergone previous access surgery. All grafts were between the brachial artery and the axillary vein. RESULTS: Clinical details were similar between the groups; overall mean(s.d.) follow-up was 469(398) days. After 1 year, there were no significant differences in primary patency (28 per cent for SG 100 versus 48 per cent for ePTFE; P = 0.290), assisted primary patency (52 versus 64 per cent; P = 0.430) or secondary patency (57 versus 68 per cent; P = 0.370). Freedom from infection at 1 year was 96 per cent for SG 100 and 91 per cent for ePTFE (P = 0.410). Fifty-seven further procedures (18 endovascular and 39 surgical) were needed to maintain patency in 50 grafts (23 SG 100 and 27 ePTFE). CONCLUSION: Both grafts were adequate conduits for haemodialysis and were amenable to repair. Anticipated advantages for SG 100 were not seen in either patency or stability.

Using arteriovenous fistulae as a dual access for hemodialysis and total parenteral nutrition administration is feasible with a good outcome: a case series.

End stage renal failure patients requiring long term total parenteral nutrition (TPN) often have multiple central line placements due to line infection or occlusion. Sometimes this can cause central venous stenosis or even occlusion. We present three cases in this consecutive series, in which we have successfully used arteriovenous fistulae for both hemodialysis and long term TPN administration as an alternative route without any complications. We therefore think that native AVF and grafts can be used as dual access for hemodialysis and TPN administration provided careful case selection, counselling and follow-up.

[Anatomic variations of the vascularization of the pelvic kidney: apropos of a case and review of the literature]. / Variations anatomiques de la vascularisation des reins pelviens: à propos d'un cas et revue de la littérature.

Blood supply in pelvic kidney presents with more anatomic variations than in a normal positioned lumbar kidney. We report a patient with a right pelvic kidney and a particularly atypic vascularisation. In addition we present a review of the literature with all possible pelvic arterial variations and their frequency.

Ventriculo-atrial shunt via the left axillary vein--a novel approach.

This report describes a technique to divert cerebrospinal fluid into the right atrium via the left axillary vein in a patient in whom other methods had been attempted without success.

Molecular diagnosis of a vascular prosthesis infection, due to Propionibacterium acnes, by amplification and sequencing of 16S rDNA.

We describe a case of indolent vascular prosthesis infection due to Propionibacterium acnes. The microorganism was identified only by amplification and sequencing of 16S rDNA, while standard cultures remained negative. This observation underscores the usefulness of molecular techniques for the diagnosis of infection caused by fastidious microorganisms.

Sudden-onset paraplegia due to thrombosis of false aneurysm: late complication after prosthetic replacement of the descending thoracic aorta.

Traumatic rupture involving the isthmus of the descending thoracic aorta is a rarely treated injury in vehicular accident victims. A possible long-term complication of prosthetic replacement of the damaged aortic segment is false aneurysm. This report describes a case of sudden-onset acute paraplegia resulting from thrombosis of a false aneurysm associated with a prosthesis placed 10 years earlier for repair of traumatic rupture of the aortic isthmus.

Forearm arteries entrapment syndrome: a rare cause of recurrent angioaccess thrombosis.

Entrapment syndrome below or just above the elbow is uncommon. These rare causes of neurologic or vascular entrapment are linked to anomalous anatomical structures. No case of entrapment syndrome has been reported in patients with angioaccess for hemodialysis. We report, for the first time, forearm arteries entrapment in two patients presenting with recurrent angioaccess for hemodialysis thrombosis. Anatomical, radiologic, and surgical features of these uncommon syndromes are discussed.

Posterior approach for simultaneous access to the popliteal and anterior tibial arteries: applications to distal arterial bypass.

Arterial surgery to salvage the lower limb tends to make use of the great saphenous vein, harvested with the subject in the supine position. If this is not possible the small saphenous vein is used, harvested with the subject in the prone position, however this requires a perioperative modification of the procedure. A bypass between the popliteal and anterior tibial arteries can be performed using either a lateral or a medial and lateral approach with the patient supine. In the event of trophic disorders of the lateral compartment of the leg, these approaches are not applicable. In such cases we propose a single posterior approach. The single posterior approach was used on 10 lower limbs from 5 cadavers in the prone position. Approach to the lower part of the popliteal artery was undertaken posteriorly between the two heads of gastrocnemius. The small saphenous vein was entirely dissected 10 cm above the lateral malleolus, the Achilles tendon and short fibular vessels were retracted medially to expose the interossous fascia, which was divided over 10 cm. Medial rotation of the limb by 30 degrees exposed the anterior tibial artery. For 3 of the lower limbs an 8 cm fibular resection was necessary, whereas on the remaining 7 medial rotation enabled excellent exposure of the anterior tibial artery. The single posterior approach to the anterior tibial artery can be applied in cases requiring distal bypass, using the small saphenous vein, between the inferior part of the popliteal artery and the anterior tibial artery.

Endovascular repair of aortic allograft aneurysmal degeneration: a case report.

Aortoenteric graft fistula remains a dreadful complication of aortic surgery. Good results have been reported using in situ graft replacement with arterial allografts. Late aneurysmal degeneration of the graft itself may necessitate further repair. We report the case of such an aneurysmal degeneration 7 years after implantation of the allograft. Endovascular repair was performed with a Vanguard device; complete exclusion was obtained immediately. At 6-month follow-up, the patient was alive and well. Duplex and computed tomography scans showed an excluded aneurysm with a slight reduction in size. Endovascular stent grafting may be a therapeutic option for treating patients with late allograft degeneration.

Bilateral carotid dissection and factor V mutation: a second case.

A young woman 38 years of age underwent Doppler ultrasonography following the spontaneous appearance of cervical pain causing loss of sleep. The examination revealed bilateral dissection of the internal carotid arteries, confirmed by supraaortic arteriography. Two successive CT scans showed no cerebral lesions. A thrombosis of the great saphenous vein was recorded as the only vascular event in her medical history. Thrombophilia was assessed following discovery of the dissection, and upon examination a heterozygotic mutation of Factor V Leiden was revealed. This observation is the second case of carotid dissection occurring in a subject presenting a factor V mutation. At the present time, however, there are no results to justify the assumption of a direct link between these two pathologies.

Influence of coronary artery and contralateral carotid artery status on long-term results of carotid artery surgery.

The main cause of death and long-term disability of patients undergoing carotid artery surgery is coronary artery disease. To identify the prognostic value of the status of the contralateral artery, we studied the course of 224 consecutive patients in whom one or both carotid arteries were operated on at our institution between 1985 and 1995. The 224 patients were divided into three groups: group I (n = 56) had an occluded contralateral carotid artery, in group II (n = 56) both carotids were operated on, and group III (n = 112) had a normal contralateral carotid artery. The clinical status of all patients except one was ascertained by one of us. We found that the status of the contralateral artery does not influence the long-term prognosis of patients undergoing carotid artery surgery. A periodic cardiological and vascular follow-up of these patients seems warranted to improve their survival.

Peroperative factors influencing the outcome of elective abdominal aorta aneurysm repair.

PURPOSE: To identify perioperative variables which may influence mortality of elective abdominal aneurysm repair (AAA). METHOD: prospective study of patients undergoing elective AAA repair between 1986 and 1997. RESULTS: Four hundred and seventy patients (438 men, 32 females) with a mean age of 69.4+/-13 years and aneurysms with a diameter of 60+/-3 mm were operated on with a 1-month mortality rate of 5.3%. Multivariate analysis identified the following independent risk factors for mortality: age >70 (p<0.0001), a past history of myocardial infarction (p<0.0001), preoperative renal insufficiency (p<0.0001), reoperation (p<0.0001), colonic necrosis (p<0.0001), and severe postoperative medical complications (p<0.0001). CONCLUSION: Intra- and postoperative events affect the outcome of AAA repair, independently of preoperative factors, and should be described when presenting the results of AAA repair.

Upper limb ischemia after subclavian flap aortoplasty: unusual long-term complication.

Repair of isolated coarctation of the aorta by subclavian flap aortoplasty carries the disadvantage of impaired blood supply to the left arm. However, ligation of branches of the subclavian artery can be tolerated without manifest ischemia of the upper extremity. We report the case of a young man who suffered from left upper extremity ischemia 18 years after initial operation. Treatment consisted of carotid-subclavian bypass with good outcome. The surgical approach of coarctation by subclavian aortoplasty should be reserved for specific cases, and if this procedure is performed, ligation of branches of the subclavian artery should be minimized to increase inflow into the left brachial artery.

Preoperative assessment of the efficacy of distal radial artery ligation in treatment of steal syndrome complicating access for hemodialysis.

Hand ischemic steal syndrome due to a forearm arteriovenous fistula is a rare occurrence. We report here a case in which we applied a new diagnostic method to assess the efficacy of distal radial ligation to treat this syndrome. A favorable comparison of distal radial artery pressure measurements before and after temporary occlusion of the artery with a balloon catheter indicated that perfusion of the hand would be dramatically improved after surgical artery ligation.

[Do the long-term results of carotid surgery influence the status of the contralateral carotid artery?]. / Les résultats à long terme de la chirurgie carotidienne sont-ils influencés par l'état de la carotide controlatérale?

AIM: The main cause of long-term death and disability of patients undergoing carotid artery surgery is coronary artery disease. To identify the prognostic value of the status of the contralateral artery, we studied the course of 224 patients operated consecutively on one or both carotid arteries in the same institution between 1985 and 1995. PATIENTS AND METHODS: The 224 patients were divided into three groups: group I (n = 56) having an occluded contralateral carotid artery; group II (n = 56) in which both carotids were operated on; and, group III (n = 112) having a normal contralateral carotid artery. The clinical status of all patients was ascertained by one of us for all patients except one. This study concerned also the course of 40 patients (group R) belonging to the three groups, who had during the follow-up period a coronary and/or a peripheral vascular intervention with a preoperative coronarography. RESULTS: The median follow-up was 62.8, 78 and 65 months for groups I, II and III, respectively. Actuarial survival rates were 67%, 73%, 72.5% at 5 years, and 39%, 51.5% and 42% at 10 years, for group I, II and III respectively. Actuarial stroke-free rates were 96%, 100%, 91% at 5 years, and 96%, 100% and 78.5% at 10 years for group I, II and III respectively. Actuarial cardiac death rates were 26%, 23%, 19% at 5 years, and 49%, 42% and 37% at 10 years for group I, II and III, respectively. None of the differences between the three groups regarding these three different end-points was significant. The group R fatal or non-fatal cardiac event-free rates at 5 and 10 years were 88% and 53% respectively. When compared with the rates of other patients (without revascularization): 68% and 25.5% at 5 and 10 years, the results were almost significant (P = 0.07). Average age for group R patients was significantly lower (65 vs. 69 years, P < 0.05). Using Cox's model, age alone emerged as a factor influencing survival (P = 0.07) but not revascularization (P = 0.13). CONCLUSION: The status of the contralateral artery does not influence the long-term prognosis of patients undergoing carotid artery surgery. A periodic cardiological and vascular follow-up of these patients tends to improve their survival.

Influence of the status of the contralateral carotid artery on the outcome of carotid surgery.

From 1985 to 1995, 747 carotid arteries were operated on in 694 patients, who were under general anesthesia and continuous electroencephalogram (EEG) monitoring. These patients were divided into three groups according to contralateral carotid status. Group 1 consisted of 58 patients who had contralateral occlusion; group 2, 53 patients who had contralateral stenosis and bilateral staged surgery; and group 3, 583 patients who had nonstenotic contralateral internal carotid artery. All groups were similar with regard to age and sex ratio. There were more asymptomatic patients in group 3 than in group 1 (39.9% vs. 25.8%) (p < 0.05), and less preoperative strokes in group 2 than in the other groups (3.7% vs. 17.2% and 13. 6%, respectively) (p < 0.05). Among risk factors, smoking was less frequent in group 3 (59.5%) than in group 1 (82.7%) and group 2 (77%) (p < 0.01), and coronary artery disease was more frequent in group 2 (60%) than in group 1 (32.7%) and Group 3 (26.4%) (p < 0.01). EEG changes occurred more frequently in group 1 (25.8%) than in group 2 [5.6% (first stage) and 3.8% (second stage)] and in group 3 (4.9%) (p < 0.01). A shunt was used only when EEG changes did not disappear after pharmacologic increasing of central blood pressure, which occurred more frequently in group 1 (10.3%) than in group 2 (0%) and group 3 (0.3%) (p < 0.05). The combined morbidity/mortality rate was similar for groups 1 and 3 (1.7% and 1.5%, respectively), however, transient morbidity was more frequent in group 1 (6.9%) than in group 3 (1.5%) (p < 0.05). The combined morbidity/mortality rate was higher in group 2 than in group 3 (7.5% vs. 1.5%) (p < 0. 05), and all strokes in group 2 were seen during the second-stage operation. In conclusion, contralateral carotid artery occlusion had minimal influence over carotid surgery results. Selective use of a shunt based on EEG monitoring prevented ischemic strokes, with minimal neurologic morbidity. Contralateral carotid stenosis did not affect operative strategy for first stage, but we noted a higher incidence of strokes during the second procedure.