Ischaemic colitis after endovascular repair of an infrarenal abdominal aortic aneurysm: a case report.

INTRODUCTION: Endovascular repair of abdominal aortic aneurysms (EVAR) has proven to be an attractive and successful alternative to traditional open surgery in properly selected patients. As in open surgery, ischaemic colitis remains a feared complication, but the incidence and causes are not properly documented. OBJECTIVE: To present a case of endovascular aneurysm repair complicated by postoperative unilateral graft limb occlusion and ischaemic colitis. CASE REPORT: A 76-year-old woman presented with diffuse abdominal pain in the presence of an infrarenal abdominal aorta aneurysm of 5.5 cm. Based on CT and calibrated angiography, the patient was selected for endovascular repair which was performed with an Excluder bifurcation graft (W. L. Gore & Associates Inc., Newark USA). The endograft was placed successfully, but completion angiography showed a kinking of the left graft limb at the level of the aortic bifurcation. The patient developed acute ischaemia of the left limb 3 days postoperatively. Treatment consisted of femorofemoral cross-over graft. One week postoperatively she developed diarrhoea. A sigmoidoscopy was performed, showing ischaemic colitis grade I. In spite of the initial good result of conservative therapy, she had to undergo a left hemicolectomy with manual colorectal anastomosis and protective ileostomy 25 days later. Despite this intervention, the patient developed multiple organ failure and died after 2 months. CONCLUSION: Postoperative ischaemic colitis has been described in extenso after open aneurysm repair. The incidence after endovascular repair is not well described. From 1998 to 2005, we performed 52 endovascular procedures with a bifurcation endoprosthesis in the treatment of an infrarenal abdominal aortic aneurysm. We report one patient out of this series, who developed an ischaemic colitis after the procedure. Possible causes include cholesterol embolization and peroperative exclusion of the inferior mesenteric artery of which the consequences might be aggravated in our patient by subsequent thrombosis of the left graft limb.

The case for urgent carotid endarterectomy.

The high mortality rate previously reported and the absence of proven advantage of urgent carotid endarterectomy over natural history, has discouraged consideration of this operation. We want to report on two patients with stroke in evolution and fluctuating stroke, who underwent immediate surgery with excellent results. With these cases we aim to demonstrate that selected patients with stroke in evolution or fluctuating stroke due to recent carotid thrombosis have a good prognosis after emergency surgery. We think that in these selected cases endovascular therapy is at this moment a waste of time.

[Popliteal cyst with venous compression]. / Popliteale cyste met veneuze compressie.

Baker's cysts can produce pressure on draining lymphatics and veins in the knee, producing oedema of the lower leg. These cysts are often mistakenly treated as deep vein thrombosis.

Intraoperative assessment of cerebral ischemia during carotid surgery.

One of the problems in carotid surgery is the intraoperative detection of brain ischemia. None of the methods (EEG; stump pressure) applied so far have been successful. Branston et al. (1974) found a threshold relationship between cortical cerebral blood flow and cortical somatosensory evoked potential (SEP). As the local blood flow fell below about 16 ml/100 g/min a progressive reduction occurred in the amplitude of the cortical evoked potential (N20/P25), implying a fundamental failure of neuronal function in the somatosensory cortex. We have monitored cortical SEP (somatosensory evoked potential) during 734 CEA's (carotid endarterectomies) in order to find an index of risk of incipient cerebral ischemia during carotid cross-clamping, to determine the need for shunting and the causes of early irreversible neurologic deficits. In 59 cases evaluation of SEP was not possible because of technical difficulties. During 586 CEA's no alteration of SEP occurred. However, 4 patients had an immediate postoperative neurologic deficit, while the SEP remained normal. Abnormal SEP occurred in 89 cases and in 6 of these an irreversible loss of SEP was seen. These patients awoke with a new neurologic deficit. We found a reversible abnormal SEP in 83 cases. Reversible changes of SEP occurred mainly during carotid clamping. The diagnostic sensitivity of intraoperative SEP monitoring in predicting neurologic outcome was 60% with a specificity of 100%.

Monitoring of somatosensory evoked potentials in carotid surgery: results, usefulness and limitations of the method.

We have monitored cortical somatosensory evoked potentials (SEP) during 177 carotid operations (167 carotid endarterectomies). An intraluminal shunt was always used for endarterectomy of the internal carotid artery (CEA). SEP was not readable in 21 operations. During 126 carotid operations, no alteration of SEP occurred. However, three patients had an immediate postoperative neurologic deficit while the SEP remained normal. Abnormal SEP occurred in 30 patients. In two cases irreversible loss of SEP was seen. Both patients awoke with a new neurologic deficit after the operation. We found reversible abnormal SEP in 28 cases. In 63 cases with contralateral stenosis, abnormal SEP caused by carotid clamping was observed in 15 (24%). The diagnostic sensitivity of intraoperative SEP monitoring in predicting neurologic outcome following carotid operation was 100% with a specificity of 40%. Monitoring of SEP during carotid surgery is a reliable and useful method to detect incipient cerebral ischemia and to determine the need for shunting. The prognostic value of SEP monitoring to predict postoperative neurologic deficits is limited by the low specificity of the method.

Is venous patch grafting after carotid endarterectomy able to reduce the rate of restenosis? Prospective randomized pilot study with stratification.

Many studies have already demonstrated that the restenosis rate after carotid endarterectomy is greater as expected since ultrasound examination has become a routine procedure after endarterectomy. The purpose of our randomized study is to compare the rates of restenosis with two methods of carotid endarterectomy--direct suturing and autologous vein grafting. Sofar restenosis are found after endarterectomy and direct suturing. Different possible causes for restenosis are discussed. We hope to inform soon if patching with the autologous vein is the best method in order to prevent early restenosis after CEA.

Subclavian steal syndrome in a congenitaly anomalous subclavian artery: a case report.

The case of a 50 year-old man with a subclavian steal syndrome caused by an occlusive lesion of an aberrant right subclavian artery is presented. There was no dysphagia lusoria. The right subclavian artery was anastomosed to the right common carotid artery. At follow-up, 18 months later, the patient is symptom free and the right subclavian artery is patent.

[Changes in somatosensory evoked potentials in carotid desobliteration. Diagnostic significance and possible consequences for therapy]. / Veränderungen somatosensibel evozierter Potentiale während Karotis-Desobliteration. Diagnostische Bedeutung und mögliche Konsequenzen für die Therapie.

The cerebral function of 55 patients with stenosis and occlusion of carotid arteries was monitored intraoperatively by serial examination of somatosensory cortical evoked potentials (SEP). In 40 uncomplicated operations no significant alteration of the SEP was detected. In 13 examination series, however, reversible abnormalities were noted. Furthermore, in two cases irreversible SEP loss was documented. The nature and temporal development of SEP alterations enabled differentiation of possible etiological factors. Bilateral abnormalities were indicative of global hypoxemia whereas acutely arising unilateral SEP loss suggested embolic occlusion of cerebral arteries. Intraoperative SEP monitoring therefore appears to be of diagnostical and differential diagnostical value and allows statements in respect to further intra- and postoperative treatment.

The use of somatosensory evoked responses in carotid surgery for monitoring brain function.

One of the problems in carotid surgery is the intra-operative detection of brain ischemia. None of the methods applied so far have been successful. Experience has shown that the results were unsatisfactory. Experimental studies have detected a strong correlation between regional cerebral blood flow and somatosensory evoked potentials. At the Surgical Clinic of the University of Cologne, 60 patients had continuous intraoperative monitoring of somatosensory evoked responses during carotid endarterectomy. Our previous experiences suggest that monitoring of somatosensory evoked responses during carotid endarterectomy provides a suitable method for the registration of brain function. Furthermore it is possible to pinpoint the causes of ischemia and to immediately begin treatment based on the causes of ischemia.

[Early morbidity and fatality following carotid disobliteration]. / Die Frühmorbidität und Letalität nach Karotisdesobliteration.

At the University Hospital of Cologne-Lindenthal 260 patients underwent carotid endarterectomy during a period of 10 years. 9 patients died, representing an operative mortality rate of 2.9%. 80% of our patients with an acute stroke died. We see no indication for surgery in acute stroke. Postoperatively, 20 patients had a neurologic deficit, transient deficits occurred in 3,6% (11 patients) permanent deficits in 3% (9 patients). Carotid endarterectomy may be complicated by cranial nerve damage. The importance of these injuries is evident if bilateral carotid endarterectomy is being considered.

[Carotid stenosis surgery: results after 10 years' experience]. / De carotisdesobliteratie: resultaten na 10 jaar ervaring.

From 1973 to July 1983 220 patients at the University clinic of Cologne, Germany, had carotid endarterectomies for carotid stenosis. A shunt has always been used. The procedure mortality and morbidity were 3,4% and 6,3% respectively. We do not see any indication to operate in acute stroke.

[Venous thrombectomy]. / La thrombectomie veineuse.

The aim of surgical treatment of acute deep venous thrombosis is to prevent lethal pulmonary emboli, the venous desobstruction and the maintenance of the valvular mechanism. From 1972 to 1982, 161 patients have been operated at the surgical clinic of Cologne. In 41.4% of the cases the long term result was excellent. The clinical examination, the complaints of the patients, the phlebography were judgement criteria.