Outcomes for cervicomediastinal vascular trauma managed by a vascular subspecialistled vascular trauma service.

BACKGROUND: The management of cervicomediastinal vascular trauma is challenging. We report on our experience with the condition in a newly established vascular trauma service unit, and compare the outcomes to those reported in our parent vascular surgery department. METHOD: The details of patients with cervicomediastinal vascular injuries from January 2012 to June 2014 were retrieved for analysis from a prospective database. RESULTS: Ninety-three patients were identified, 84 of whom were male (90%), with an average age of 29 years. Most were penetrating injuries (89%), and 87% of these were due to stab wounds. There were 107 vascular injuries, 88 cervical and 19 mediastinal. Of these, 87 were arterial and 20 venous injuries. The most common arterial injury involved the subclavian artery (24%), followed by the common carotid artery (22%). Management was multimodal, and included conservative (8%), stenting and embolisation (8%), referral to a higher centre (8%), vascular repair (64%) and ligation (12%). Nineteen per cent required median sternotomy or thoracotomy. Eight patients died postoperatively (9%). Seven of them presented in extremis and died within 24 hours, and one died after a week from associated abdominal injuries. Postoperative complications were 9%. There was no incidence of a stroke or limb loss despite ligation of the arteries, including ligation of four internal carotids. CONCLUSION: The development of endovascular techniques would allow for noninvasive management of a significant number of patients. Open surgery is still necessary, and associated with significant morbidity. Comparable results were reported in our newly established vascular trauma service unit to those obtained in our parent vascular surgery department in Durban.

Comparison between superficial femoral artery stenting and bypass surgery in severe lower-limb ischaemia: a retrospective study.

BACKGROUND: Symptomatic femoro-popliteal disease is treated by bypass surgery or angioplasty with or without stenting. The aim of this study was to compare the results of stenting and bypass surgery with regard to limb salvage in patients with severe leg ischaemia. METHODS: A total of 213 patients with femoro-popliteal disease presenting with severe claudication or critical limb ischaemia between January 2009 and December 2013 were evaluated; 118 patients (139 limbs) had stents placed and 95 patients (104 limbs) had bypass surgery. Most (60%) presented with critical limb ischaemia (rest pain 40%, tissue necrosis 20%), and the remainder with severe claudication. The treatment groups had matching risk factors. RESULTS: The average age was 66 years and 73% were male. Tissue necrosis was found in 26% of the stent group and 12% of the bypass group (p = 0.009). In the stent group 26% had adjunctive procedures, compared to 16% in the bypass group (p = 0.138). During the one-year follow up, there were 30 stent occlusions (22%) and 18 graft occlusions (17%) (p = 0.42). There were 14 major amputations (10%) in the stent group, and 13 (13%) in the bypass group (p = 0.68). Limb salvage rate was 90% in the stent group, and 88% in the bypass group (p = 0.68). There were no peri-operative deaths in the stent group, but one in the bypass group (1%). One-year mortality rate was equal (8%) in both groups (p = 1.00). CONCLUSION: One-year outcome was comparable in both groups with regard to mortality, stent or graft patency and limb salvage rates.

Descriptive retrospective analysis of the diagnostic yield and morbidity of four vessel catheter-directed cerebral angiography and multidetector computed tomographic angiography (MDCTA) performed at Inkosi Albert Luthuli Central Hospital (IALCH).

Imaging studies are indispensable in order to determine the source, location and pattern of intra and extra-axial brain haemorrhages. In our study of 277 patients carried out over an 18 month period, the most common reason of referral was subarachnoid haemorrhage followed by trauma. Aneurysms were the most common diagnosis (36%) with anterior and posterior communicating arteries being the most common locations. Fifty percent (50%) of patients investigated had a normal study. Our findings show that the yield from MDCTA and conventional angiography was relatively comparable, however, conventional angiography was superior in detection of aneurysms; hence, in cases were the MDCTA result was found to be normal despite a high index of suspicion for a subarachnoid haemorrhage, a follow-up MDCTA study or conventional angiography is useful. Moreover, conventional angiography was superior in detection of multiple aneurysms.

Management of HIV vasculopathy - a South African experience.

UNLABELLED: The aim of the study was to describe the presentation management and short term results of therapy (< 1 month) in patients admitted with HIV vasculopathy. Records were culled from a prospectively maintained data base on the Vascular Unit at Inkosi Albert Luthuli Hospital, Durban, South Africa between January 2005 and June 2009. 226 patients were studied; 111 had aneurysms and 115 occlusive disease. 98% were African and ages ranged from 4-53 years (average 36); 90% were male. The CD4 count ranged from 1-930 cells/mm(3) while serum albumin averaged 30 mMol/L. 202 aneurysm presented in 111 participants; commonest sites were superficial femoral artery (40%) and carotid (25%). 82 patients had standard operative repair and 8 had stent grafts; 29 were not treated due to advanced disease. Within 30 days of operation the mortality was 9% with 5% developing graft sepsis and 11% pulmonary complications. Of 115 with occlusive disease, there were 2 distinct groups. 51 had no previous claudication and had acute thrombosis; no thrombophilia could be demonstrated. 64 had premature atherosclerotic disease. The majority presented with critical ischaemia. In the acute thrombosis group 15 (29%) had primary amputation, limb salvage was achieved in 13 (36%) and 4 died (11%). In the chronic occlusive group 30 (47%) had primary amputation, of 25 submitted to surgery limb salvage was achieved in 17 (68%). Low CD4 count and albumin levels did not correlate with mortality or complications. CONCLUSION: Surgical therapy for aneurysm is worthwhile in the short term. Following occlusive disease there is a 25% overall salvage rate in the short term (< 1/12) but the long term outlook is uncertain.

A retrospective review of brachial artery injuries and repairs--is it still a "training artery"?

BACKGROUND: A retrospective analysis of operatively managed brachial artery injuries spanning a five-year period from January 2003 to December 2007. METHODS: The medical records of all patients who had operative management of brachial artery injuries were reviewed. Demographic data, mechanism of injury, pathology of injury, associated injuries, duration of injury, operative management and outcomes were analysed. RESULTS: A total of 115 patients were included in the review. Twelve patients (10.4%) were female and 103 (89.6%) were male. The mean age was 27.3 years with the oldest patient being 70 years and the youngest 13 years. Most of the injuries were caused by stabs to the brachial artery (53%). 33% were due to gunshot wounds, 11.3% were due to blunt trauma and 2.9% were due to other mechanisms of injury. The majority of injuries (58.3%) were repaired with a reverse saphenous vein graft. Most patients had a pulse restored on discharge with only 4.4% of repairs occluding and of the repairs that occluded only one patient needed an ablation. Four patients (3.5%) had an ablation due to a non-viable limb. 13.9% of patients had a fasciotomy, 54.8% had an associated peripheral nerve injury and 14.8% had an associated venous injury. CONCLUSION: Brachial artery injuries are still common in our practice, with most being managed operatively. Due to the good collateral circulation in the arm, most brachial artery injuries do not result in limb loss even with a significant time delay and even when the repair occludes. Brachial artery injuries are thus a good vessel for surgical registrars to train on.

Carotid intervention: stent or surgery? A prospective audit.

This study represents a prospective audit comparing carotid artery stenting (CAS) with carotid endarterectomy (CEA), performed by a single surgical team. Between January 2005 and December 2008, 440 patients were referred; 177 had CAS and 263 CEA. Selection of procedure was individualised and contra-indications for CAS included internal carotid artery (ICA) stenosis > 85-90%, intraluminal thrombus, ICA tortuosity, gross surface ulceration of plaque and excessive calcification. Type III aortic arch and arch calcification also precluded CAS. Standard techniques were used for both procedures with a protection device routinely used for CAS. Most CEAs were performed under general anaesthesia, with selective intraluminal shunting. One hundred and eighty-six patients were selected for CAS; nine (48% ) were converted to CEA for technical reasons. The operative risk profile was similar, but significantly more in the CAS group were hypertensive. Almost half (49% ) in the CAS group were asymptomatic vs 26% in the CEA group. All asymptomatics had 70+ % stenosis on Duplex Doppler. Results were reported within one month of the procedure. The stroke rate was 2.3% for CAS vs 1.9% for CEA (p > 0.05). Stroke and death plus one M1 was 4.5% after CAS vs 3.4% after CEA (p > 0.05). Disabling stroke occurred in 1.1% of CAS patients vs 0.4% of CEA patients. These results are satisfactory and compare favourably with other similar series.

The influence of diabetes on short-term outcome following a prosthetic above-the-knee femoro-popliteal bypass.

OBJECTIVES: To assess the influence of diabetes mellitus on early morbidity and mortality following a femoro-popliteal bypass. METHODS: Clinical data on patients subjected to a prosthetic above-the-knee femoro-popliteal bypass for atherothrombotic disease over a four-year period in the Durban Metropolitan Vascular Service were culled from a prospectively maintained computerised database. The patients were divided into two groups, diabetic and non-diabetic. RESULTS: Two hundred and seventeen patient records were analysed; 102 (47%) patients were diabetic and 115 (53%) non-diabetic. The mean age in the two groups was almost similar. Differences noted between the two groups were that there was a higher prevalence of males and cigarette smokers in the non-diabetic group and hypertension among the diabetics. The prevalence of ischaemic heart disease in the two groups was not statistically significant. The majority of patients in both groups presented with critical limb ischaemia. Overall, 208 (96%) of the patients had their procedures performed using loco regional anaesthesia. The incidence of superficial wound infection between the two groups was not statistically significant. Deep infection, which necessitated removal of the graft, and cardiovascular complications were significantly higher in the diabetics. Four patients (3.9%) in the diabetic group and only one (0.9%) in the non-diabetic group died. CONCLUSION: Diabetes mellitus significantly increases the incidence of graft sepsis and cardiovascular morbidity in patients undergoing above-the-knee femoro-popliteal bypass.

Carotid artery stump pressure and associated neurological changes in predominantly symptomatic carotid artery disease patients undergoing awake carotid endarterectomy.

AIM: To determine the mean carotid artery stump pressure (SP) at which patients develop neurological changes while undergoing awake carotid artery endarterectomy (CEA) under cervical block anaesthesia (CBA). METHODS: A prospective analysis was carried out of patients undergoing awake CEA under CBA between February 2004 and April 2007. All patients had mean SP measured, with selective shunting on those who developed neurological symptoms on carotid artery clamping regardless of stump pressure. A ball connected to a pressure sensor was put in the patient inverted exclamation mark s contra-lateral hand. RESULTS: Fifty-nine patients had awake CEA, 40 were males with a mean age of 64 years. Indications for CEA were asymptomatic high-grade stenosis in 12 (20%) patients and symptomatic stenosis in 47 (80%). Seven (12%) patients required shunting, one for transient ischaemic attack (TIA) and six for loss of consciousness. Six of these patients had presented with symptomatic disease. Taking the threshold of mean carotid SP of 50 mmHg as an indication for shunting, 22% (6/27) of patients with a mean SP of < 50 mmHg required shunting and only 3% (1/32) with a mean carotid SP of > 50 mmHg needed a shunt. This was not statistically significant. Using a mean carotid SP of < or = 40 mmHg as the threshold for shunting, 40% (4/10) of patients required shunting and 3% (1/31) with a mean carotid SP of > 40 mmHg required shunting. This was statistically significant. Thirteen (22%) patients were complicated by transient hoarseness of voice. One (2%) had a haematoma that required re-exploration. None of these patients had any major postoperative neurological or cardiological complications. CONCLUSION: Even though the sample in this study was small, awake CEA under local anaesthesia was seen as a safe procedure. It would appear to be safe to use the mean SP of 40 mmHg as a threshold for selective shunting in CEA under general anaesthesia.

Carotid Artery Stump Pressure and Associated Neurological Changes in Predominantly Symptomatic Carotid Artery Disease Patients Undergoing Awake Carotid Endarterectomy : Cardiovascular Topics

Aim : To determine the mean carotid artery stump pressure (SP) at which patients develop neurological changes while undergoing awake carotid artery endarterectomy (CEA) under cervical block anaesthesia (CBA). Methods : A prospective analysis was carried out of patients undergoing awake CEA under CBA between February 2004 and April 2007. All patients had mean SP measured; with selective shunting on those who developed neurological symptoms on carotid artery clamping regardless of stump pressure. A ball connected to a pressure sensor was put in the patient's contra-lateral hand. Results : Fifty-nine patients had awake CEA; 40 were males with a mean age of 64 years. Indications for CEA were asymptomatic high-grade stenosis in 12 (20) patients and symptomatic stenosis in 47 (80). Seven (12) patients required shunting; one for transient ischaemic attack (TIA) and six for loss of consciousness. Six of these patients had presented with symptomatic disease. Taking the threshold of mean carotid SP of 50 mmHg as an indication for shunting; 22(6 / 27) of patients with a mean SP of 50 mmHg required shunting and only 3(1 / 32) with a mean carotid SP of 50 mmHg needed a shunt. This was not statistically significant. Using a mean carotid SP of ? 40 mmHg as the threshold for shunting; 40(4 / 10) of patients required shunting and 3(1 / 31) with a mean carotid SP of 40 mmHg required shunting. This was statistically significant. Thirteen (22) patients were complicated by transient hoarseness of voice. One (2) had a haematoma that required re-exploration. None of these patients had any major postoperative neurological or cardiological complications. Conclusion : Even though the sample in this study was small; awake CEA under local anaesthesia was seen as a safe procedure. It would appear to be safe to use the mean SP of 40 mmHg as a threshold for selective shunting in CEA under general anaesthesia

The Influence of Diabetes on Short-Term Outcome Following a Prosthetic Above-The-Knee Femoro-Popliteal Bypass : Cardiovascular Topic

Objectives: To assess the influence of diabetes mellitus on early morbidity and mortality following a femoro-popliteal bypass. Methods: Clinical data on patients subjected to a prosthetic above-the-knee femoro-popliteal bypass for atherothrombotic disease over a four-year period in the Durban Metropolitan Vascular Service were culled from a prospectively maintained computerised database. The patients were divided into two groups; diabetic and non-diabetic. Results: Two hundred and seventeen patient records were analysed; 102 (47) patients were diabetic and 115 (53) non-diabetic. The mean age in the two groups was almost similar. Differences noted between the two groups were that there was a higher prevalence of males and cigarette smokers in the non-diabetic group and hypertension among the diabetics. The prevalence of ischaemic heart disease in the two groups was not statistically significant. The majority of patients in both groups presented with critical limb ischaemia. Overall; 208 (96) of the patients had their procedures performed using loco regional anaesthesia. The incidence of superficial wound infection between the two groups was not statistically significant. Deep infection; which necessitated removal of the graft; and cardiovascular complications were significantly higher in the diabetics. Four patients (3.9) in the diabetic group and only one (0.9) in the non-diabetic group died. Conclusion: Diabetes mellitus significantly increases the incidence of graft sepsis and cardiovascular morbidity in patients undergoing above-the-knee femoro-popliteal bypass

Carotid Intervention : Stent or Surgery? A Prospective Audit : Cardiovascular Topic

This study represents a prospective audit comparing carotid artery stenting (CAS) with carotid endarterectomy (CEA); performed by a single surgical team. Between January 2005 and December 2008; 440 patients were referred; 177 had CAS and 263 CEA. Selection of procedure was individualised and contra-indications for CAS included internal carotid artery (ICA) stenosis 85-90; intraluminal thrombus; ICA tortuosity; gross surface ulceration of plaque and excessive calcification. Type III aortic arch and arch calcification also precluded CAS. Standard techniques were used for both procedures with a protection device routinely used for CAS. Most CEAs were performed under general anaesthesia; with selective intraluminal shunting. One hundred and eighty-six patients were selected for CAS; nine (48) were converted to CEA for technical reasons. The operative risk profile was similar; but significantly more in the CAS group were hypertensive. Almost half (49) in the CAS group were asymptomatic vs 26in the CEA group. All asymptomatics had 70+stenosis on Duplex Doppler. Results were reported within one month of the procedure. The stroke rate was 2.3for CAS vs 1.9for CEA (p 0.05). Stroke and death plus one M1 was 4.5after CAS vs 3.4after CEA (p 0.05). Disabling stroke occurred in 1.1of CAS patients vs 0.4of CEA patients. These results are satisfactory and compare favourably with other similar series

Fluctuating pulse deficits associated with intimal arterial injury following gunshot wounds of the extremity - a sign not to be missed

Gunshot wounds may result in intimal arterial injury without breach of the arterial wall integrity. Haemorrhage; haematoma and a pulse deficit are therefore not always found. We report on two cases of lower extremity gunshot wounds with temporal variations in the clinical and radiological assessment of the pedal pulses. In both cases surgical exploration revealed intact arterial vessel walls but significant intimal injury with overlying thrombus. We propose that the pulse deficits were due to distal thromboembolism. Subsequent clot lysis led to a return of the original pulse deficit. Variation in the distal pulses in patients with gunshot wounds of the extremities should alert one of the possibility of an intimal arterial injury; imaging of the vessels is therefore advised

Transient ischaemic attack: is routine use of computerised cerebral tomography worthwhile?

AIM: To evaluate the role of routine computerised cerebral tomography (CCT) in patients undergoing carotid endarterectomy (CEA) following transient ischaemic attach (TIA). METHOD: A retrospective review was carried out of data collected on patients with TIA who were managed at the Durban Metropolitan Vascular Service over an 11-year period. All patients underwent carotid duplex scanning and CCT, followed by carotid endarterectomy (CEA) under general anaesthesia. RESULTS: The records of 140 patients were reviewed. There were 85 (61%) men and 55 (39%) women (F:M = 1:1.6). The mean age was 63 years (range 40-95 years). The presenting symptoms were amaurosis fugax, syncope and speech deficit. Risk factors for arterial disease were smoking (73%), hypertension (55%), diabetes mellitus (28%) and hyperlipidaemia (6%). Duplex ultrasonography showed significant internal carotid artery stenosis in 138 patients and occlusion in two. Arch angiography of the latter two patients showed pre-occlusive carotid stenosis. CCT scans showed abnormalities in 34 (24%) patients. These were lacunar infarcts (56%), old infarcts involving grey and white matter (32%), and cortical infarcts (12%). The findings did not influence management. All patients underwent routine CEA with selective shunting in 51 (36%) patients. Postoperative stroke rate was 2.9%. CONCLUSION: Routine CCT scanning in patients with TIA did not influence patient management and outcome. It is not cost effective and its routine use is questioned.

Thrombectomy in HIV related peripheral arterial thrombosis: a preliminary report.

OBJECTIVES: To evaluate the limb salvage rate in patients undergoing thrombectomy for HIV related peripheral arterial thrombosis. METHODS: A prospective review of patients with HIV related peripheral arterial thrombosis managed at the Durban Metropolitan Vascular Service in Kwazulu-Natal South Africa over a 5-year (1998-2003) period. All patients underwent thrombectomy. RESULTS: Twenty-two patients (20 males) with HIV related peripheral arterial thrombosis (two upper limbs, 20 lower limbs) were included in the study. The median age was 36 years (24-46 years). All patients had rest pain and seven patients had gangrene (digital five, forefoot two). Seven patients had a short history of claudication before development of rest pain. Mean duration of symptoms was 30 days (1-120 days) with 10 patients presenting within 24 h. Most patients had a good general state of health and only three had clinical evidence of HIV infection. Ten patients who presented with threatened limbs from acute arterial occlusion were subjected to thrombectomy without any diagnostic investigations. Twelve patients who did not present with critical limb ischaemia had duplex ultrasonography, which showed arterial occlusion by a thrombus with normal proximal arteries. The striking features were the normal proximal vessels and absence of distal run-off. The search for an underlying cause, echocardiography in seven patients and coagulation screening in 10 patients, was always negative. All patients were subjected to thrombectomy with an on-table angiogram and received systemic heparin intra-operatively and deltaparin post-operatively. In 20 patients, duplex ultrasonography confirmed re-thrombosis within 48 h. Two patients remained with patent arteries. Most (16/20) patients who re-thrombosed required a major amputation and thrombectomy did not alter the level of amputation. The other four patients with re-thrombosis had symptomatic relief. Three patients died within 30 days of thrombectomy, all of HIV related complications. Overall the limb salvage rate was 6/22 (27%). CONCLUSION: Limb salvage rate following thrombectomy in HIV related peripheral arterial thrombosis is very low. Duplex ultrasonography appears to be an adequate radiological diagnostic investigation for these patients.

Fluctuating pulse deficits associated with intimal arterial injury following gunshot wounds of the extremity--a sign not to be missed.

Gunshot wounds may result in intimal arterial injury without breach of the arterial wall integrity. Haemorrhage, haematoma and a pulse deficit are therefore not always found. We report on two cases of lower extremity gunshot wounds with temporal variations in the clinical and radiological assessment of the pedal pulses. In both cases surgical exploration revealed intact arterial vessel walls but significant intimal injury with overlying thrombus. We propose that the pulse deficits were due to distal thromboembolism. Subsequent clot lysis led to a return of the original pulse deficit. Variation in the distal pulses in patients with gunshot wounds of the extremities should alert one of the possibility of an intimal arterial injury; imaging of the vessels is therefore advised.

The role of clinical examination in excluding vascular injury in haemodynamically stable patients with gunshot wounds to the neck. A prospective study of 59 patients.

OBJECTIVE: To prospectively evaluate the safety and accuracy of physical examination in determining the management of stable patients with gunshot wounds to the neck. DESIGN: Prospective study of 59 patients with gunshot wounds to the neck. PATIENTS AND METHODS: Fifty-nine stable patients with gunshot wounds to the neck managed between December 2001 and August 2003. All patients had a physical examination and routine angiography according to a written protocol approved by the research ethics committee. The sensitivity, specificity, and predictive values of physical examination were assessed and compared with the angiographic findings. RESULTS: Thirteen patients with positive findings on physical examination (history of bleeding, haematoma, minimal bleeding, thrill, bruit and pulse deficit) and 10 patients without clinical signs of vascular injury had vascular injury. A sensitivity of 57%, specificity 53%, positive predictive value 43% and negative predictive value of 67% were calculated for physical examination alone in detecting vascular injury. CONCLUSION: Findings on physical examination are not good predictors of vascular injury in stable patients with gunshot wounds to the neck. Our findings question the validity of physical examination alone, as a safe and accurate assessment of patients with gunshot wounds to the neck. Arteriography or ultrasonography is needed to identify vascular injuries.