Spontaneous renal artery dissection: three cases and clinical algorithms.

Spontaneous renal artery dissection (SRAD) is rare. Clinical manifestations vary from minimal symptoms to life-threatening hypertension. We analysed three cases from our institution and conducted a literature review in order to design diagnostic and treatment algorithms for SRAD.

Management of deep venous thrombosis in the pregnant female.

Deep venous thrombosis of the lower extremities is an uncommon but dreaded complication of pregnancy which can present diagnostic and therapeutic problems to the treating physician. From January 1, 1985, to December 31, 1988, 7867 deliveries were performed at St. Luke's Hospital. Five of these patients were pregnant women who were treated for deep venous thrombosis of the lower extremities. The women were either in their second or third trimester of pregnancy. The clinical diagnosis in each case was confirmed with duplex ultrasonography. Each patient was treated with 7 to 10 days of intravenous heparin therapy and then discharged on subcutaneous heparin therapy. There were no bleeding complications related to the heparin therapy. No patient developed a pulmonary embolism. Each patient delivered a normal child. The only complication was a heparin induced rash in one patient which resolved when a different preparation of heparin was used. The management of deep venous thrombosis in pregnancy is discussed.

Management of extremity ischemia secondary to radiation therapy.

The protocols for treating neoplasms often involve the use of radiation therapy either as the primary treatment or as an adjunct to surgery or chemotherapy. Numerous adverse reactions can occur secondary to radiation therapy. A well known side effect is radiation induced occlusive lesions and the enhancement of normally occurring atherosclerosis. All cases of extremity ischemia in the Pennsylvania Hospital Vascular Surgical Registry, from January 1, 1967 to December 31, 1984, were reviewed. This study involves six patients who developed ischemia secondary to radiation induced arterial injury. Five cases involved the lower extremities (iliac arteries) and one case involved the upper extremity (subclavian artery). The pathologic changes occurring in these irradiated arteries and their relationship to atherosclerosis is discussed. All patients were successfully managed by arterial bypass procedures.

Inflammatory abdominal aortic aneurysm.

Between January 1976 and December 1982, 181 patients with abdominal aortic aneurysms were treated surgically, and in 13 patients the aneurysms were found to be inflammatory. Inflammatory aneurysms of the abdominal aorta (IAAA) share important characteristics with typical atherosclerotic abdominal aortic aneurysms. Diagnosis and surgical management of IAAA are distinctive which suggests that IAAA should be considered separately, as a varient of typical abdominal aortic aneurysms. IAAA occur predominantly in males. The presenting symptoms are often idiosyncratic and include severe abdominal or back pain, or both, and ureteral obstruction; the diagnosis of IAAA should be considered when these symptoms are present. Although grossly and microscopically, the perianeurysmal fibrosis resembles idiopathic retroperitoneal fibrosis, the two conditions can be differentiated. At the present time, ultrasonography and computed tomography appear to offer reliable means for diagnosing IAAA. The presence of IAAA, whether established preoperatively or discovered unexpectedly at operation, necessitate certain modifications in the surgical approach, in order to avoid injuring the duodenum and the venous structures. Most patients can be successfully treated by resection and graft replacement. Rupture of the aneurysm in IAAA appears to be less frequent than in typical atherosclerotic abdominal aortic aneurysm.

Distal thoracic aorta to femoral artery bypass: a surgical alternative.

Our experience indicates that the DTA-FA bypass is an acceptable alternative inflow procedure when more commonly used procedures are not feasible. In particular, it is suitable for patients who have undergone prior abdominal surgery or irradiation that makes additional abdominal surgery difficult or undesirable and for patients whose previous inflow operations have failed.

Sequential femoropopliteal and femorotibial bypasses. A ten-year follow-up study.

Since 1970, we have performed 33 sequential femoropopliteal bypass grafts (of 482 femoropopliteal bypasses [7%]) and 22 sequential femorotibial bypass grafts (of 153 femorotibial bypasses [14%]). Patients ranged in age from 51 to 90 years. Twenty-two (66%) of the sequential femoropopliteal bypass grafts, and all of the sequential femorotibial bypass grafts, were for limb salvage. By life table analysis, interval patency rates for both types of sequential procedures at 60 months, 72 months, and even longer are good (greater than 80% for both sequential femoropopliteal and sequential femorotibial bypasses). These two sequential bypasses are effective alternatives when the saphenous vein is inadequate. We assume that these results are due to excellent inflow (using a prosthetic graft proximally) and the use of a segment of autogenous saphenous vein over the knee joint.

Alternatives in the treatment of abdominal aortic aneurysms.

Most patients with abdominal aortic aneurysm can safely undergo aneurysmectomy. In poor-risk patients the mortality rate is greatly increased. A procedure which is a safe alternative for patients who might otherwise be denied an elective procedure is described. However, this technique for the management of abdominal aortic aneurysm is not a substitute for the classic surgical treatment.

Cystosarcoma phyllodes. Diagnosis and management.

The diagnosis and management of cystosarcoma phyllodes is analyzed by reviewing the literature and presenting cases from our institution. This rare neoplasm of the female breast represents less than 1% of all breast tumors. Most patients present in the fourth and fifth decades of life. The predominant complaint is a palpable mass in the breast. Systemic manifestations occur after metastases have developed. Treatment is surgical excision. There is some controversy, however, over which type of surgical procedure should be performed. We recommend total mastectomy. Local recurrence and metastases do occur and have been related to inadequate surgery and various histological characteristics (mitotic activity, tumor margin, and stromal cellular atypia).