Subclavian artery-to-innominate vein fistula: a case caused by subclavian venous catheterization.

Arteriovenous fistulas caused by subclavian vein catheterization occur rarely. Most subclavian vein catheters are inserted through an infraclavicular subclavian venipuncture with passage of a vessel dilator and peel-away sheath over a guidewire. We report a previously undescribed complication of this technique, namely, a right subclavian artery-to-right innominate vein fistula. The mechanism of injury was perforation through the opposing walls of the respective vein and artery due to stiffness of the vessel dilator that could not negotiate the curve from the subclavian vein to the innominate vein. Measures to avoid this complication are described.

Management of chyloperitoneum after abdominal aortic surgery.

Chyloperitoneum is a rarely reported complication of abdominal aortic surgery. From 1981 to 1992, we treated 5 cases of chylous ascites after operations on the abdominal aorta and reviewed 22 previously published cases. There were 22 men and 5 women, with a mean age of 63.8 years (range: 27 to 93 years). Twenty cases (74.7%) occurred after abdominal aortic aneurysm resection, 5 (18.5%) after aorto-femoral bypass for occlusive disease, and 2 (6.8%) after resection of infected aortic grafts, 1 for occlusive disease and the other for infrarenal aortic aneurysm. Abdominal distention was the most common presenting symptom, occurring in 26 (96.3%) of 27 patients. The mean time from aortic operation to the development of symptoms was 18.5 days (range: 7 to 120 days). Diagnosis was confirmed by paracentesis, which yielded lipemic, sterile fluid in all patients. Therapeutic paracentesis was not successful when used alone, but, when combined with a medium-chain triglyceride (MCT) diet or total parenteral nutrition (TPN), it resulted in resolution of chyloperitoneum in 8 of 14 patients (57.2%). TPN alone or with paracenteses and/or diuretics was successful in 9 of 15 (60%) patients. Peritoneovenous shunts resolved chylous ascites in four of five patients not responding to diet and/or TPN but resulted in one death due to sepsis. Operative ligation of the injured lymphatic channel was successful in all five patients treated by laparotomy when nonoperative efforts failed. Chyloperitoneum resolved in all but two (7.7%) patients. There were five (18.5%) deaths, but only three (11.5%) were directly related to chylous ascites. Treatment with TPN resolved chyloperitoneum in all five of our own patients. We reached the following conclusions: (1) Chyloperitoneum is a rare complication of aortic surgery; (2) This disorder should be considered whenever persistent abdominal distention appears after aortic surgery; (3) The diagnosis is easily confirmed by paracentesis; and (4) Surgery to close the lymph fistula should be reserved for those patients in whom conservative therapy with MCT diets or TPN has failed.

Noninvasive determination of skin perfusion pressure using a laser Doppler.

Laser Doppler (LD) measures blood flow in approximately one cubic millimeter of tissue. The LD instrument is well suited to the determination of the initiation of flow in the microcirculation after a period of arrest due to externally applied counterpressure. Radioisotope clearance and photoplethysmography have been used to measure skin perfusion pressure (SPP) in an effort to predict healing of ischemic ulcerations and amputation wounds. By placing the LD probe beneath a blood pressure cuff, SPP was measured at the forearm, thigh, calf, foot, dorsal and plantar great toe. The SPP was measured in 32 normal limbs and 26 limbs with rest pain, ulceration or gangrene. Skin of normal extremities and forearm and thigh skin of patients with ischemic lower extremities had a mean SPP of 47 mmHg (+/- 5 SEM). The SPP in ischemic extremities was significantly lower at the calf 22 +/- 4 (p less than .001), the foot 10 +/- 2 (p less than .0001), and the toe 16 +/- 4 (p less than .0001). SPP was greater at the plantar toe (73 +/- 5) than in all other locations. Skin of the plantar toe was unique among the sites measured because it is rich in arteriovenous anastomoses, which have a thermoregulatory function. The higher pressure probably reflects the fact that the larger arterioles have a higher intraluminal pressure than the capillaries and, therefore, a more proximal level of the microcirculation is measured by the LD instrument in thermoregulatory areas of the skin.(ABSTRACT TRUNCATED AT 250 WORDS)

Outcome of intraarterial urokinase for acute vascular occlusion.

Intraarterial urokinase (IAUK) was administered to 33 patients on 40 occasions for the treatment of acute extremity ischemia and long-term patency was assessed. Lysis was successful in 39 of the 40 cases (95%). Occlusive thrombus was cleared in 12 of 13 patients with native artery occlusion (7 complete, 5 partial), 8 of 9 with autologous vein grafts (5 complete, 3 partial), and in all 18 patients with synthetic grafts (17 complete, 1 partial). The primary cumulative patency following successful IAUK was 100% for native arteries and 47% for synthetic grafts at 12 months, and 23% for autologous grafts at 9 months. The difference in rethrombosis rate between autologous vein (67%) and native artery (0%) was significant (p = 0.02) as was the difference between infrainguinal prosthetic grafts (63%) and native artery (p = 0.025). IAUK is most effective for the treatment of native artery occlusion, but is significantly less effective for thrombosed infrainguinal autologous vein or synthetic grafts due to the likelihood of reocclusion, despite the high immediate success rate. For autologous vein grafts, lysis is frequently incomplete and patency rapidly deteriorates regardless of adjunctive therapy to relieve the underlying obstruction.

Gastrointestinal bleeding after aortic surgery. The role of laparotomy to rule out aortoenteric fistula.

The frequency and causes of gastrointestinal (GI) bleeding occurring after aortic surgery were evaluated retrospectively to determine the incidence of aortoenteric fistula (AEF) in relation to other causes and to place in perspective the role of laparotomy for the diagnosis of AEF. Two hundred fifty-three patients in whom aortic prostheses have been inserted were observed for a mean of 46 months. Seventy-four bleeding episodes occurred in 21% of patients between 1 and 108 months after surgery (mean 29 months). Only one AEF appeared that was associated with GI bleeding, for an incidence of 1.4% of bleeding episodes and 0.4% of grafts inserted. No diagnostic workup for GI bleeding was performed for 20 of the 74 episodes and no AEFs were noted in this group during a mean follow-up of 28 months. Diagnostic evaluation was done for the remaining 54 episodes. No cause for bleeding was identified in 16 patients and no AEF developed in this group during a mean follow-up of 26 months. A potential bleeding site was identified in 38 patients, of whom 30 had intrinsic GI lesions and no subsequent evidence of AEF during a mean follow-up of 28 months. Laparotomy for a suspected AEF was recommended for the remaining eight episodes in eight patients and was performed in six patients. An AEF was seen in one patient with abnormality found on preoperative CT scanning; an intrinsic GI lesion was identified in three patients; and no pathologic condition was found in the remaining two (negative laparotomy rate, 33%).(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of renal cell carcinoma by extracorporeal partial nephrectomy and autotransplantation using splenic vascular anastomosis.

A patient with large left lower pole renal cell carcinoma in a solitary kidney is presented. The patient was treated by partial nephrectomy and autotransplantation using splenic arterial and venous anastomoses. The potential for reducing operative morbidity compared with autotransplantation to the iliac fossa is discussed.

Angioscopic assessment of fibrinolysis for impending in situ saphenous vein graft thrombosis.

A failing femorotibial in situ saphenous vein bypass graft was found by angioscopic examination to be lined with white thrombus and was successfully treated by intraoperative lytic therapy rather than by thrombectomy with a balloon catheter. The platelet-fibrin debris was completely cleared by 250,000 units of urokinase. There were no bleeding complications and the potential for mechanical damage to the venous endothelium was prevented. The in vivo angioscopic observations of fibrinolysis are described.

The necessity for long-term antibiotic therapy with positive arterial wall cultures.

The results of treatment after excision of infected arterial grafts were analyzed as a function of aortic/arterial wall cultures and duration of antibiotic therapy in 33 patients. Four patients died during surgery and 29 patients were observed for periods ranging from 2 weeks to 76 months. Negative arterial wall cultures (NAwC) were found in 16 patients, three of whom died of multiple-organ failure and sepsis but none of whom had aortic/arterial disruption/hemorrhage. Positive arterial wall cultures (PAwC) were found in 13 patients, seven of whom received short-term, broad-spectrum antibiotics for less than 10 days (PAwC-STA) and six of whom received long-term culture-specific antibiotic therapy (intravenous therapy for 6 weeks and oral therapy for 6 months) (PAwC-LTA). Five of seven patients in the PAwC-STA group died of aortic disruption or hemorrhage, one patient had severe hemorrhage caused by disintegration of a saphenous vein patch over the common femoral artery, and one patient had a recurrent aortoenteric fistula. There were 10 episodes of arterial disruption/hemorrhage in those seven patients. All episodes of aortic/arterial disruption/hemorrhage occurred in the PAwC-STA subgroup (seven of seven patients) and none occurred in the PAwC-LTA subgroup (none of six patients) (0.005 less than p less than 0.001). The incidence of aortic/arterial disruption/hemorrhage was significantly different between overall PAwC (7 of 13 patients) vs NAwC (none of 16 patients) (0.005 less than p less than 0.001) and NAwC-STA (none of 16 patients) vs PAwC-STA (seven of seven patients) (0.001 less than p less than 0.0005).(ABSTRACT TRUNCATED AT 250 WORDS)

Fibrinolytic treatment of residual thrombus after catheter embolectomy for severe lower limb ischemia.

Intraoperative intraarterial fibrinolytic therapy (IIFT) was employed in 28 patients with acute limb ischemia. In 17 patients, significant residual calf thrombus was demonstrated by completion arteriography after standard balloon catheter thromboembolectomy, whereas in 11, pretreatment arteriography was not obtained. With the patient systemically heparinized, a bolus of fibrinolytic agent was instilled into the distal vessels below an inflow occlusion clamp. Among the 17 patients under angiographic control, arteriography was repeated after 30 minutes and a second bolus was injected if significant residual thrombus was still present. Successful lysis was achieved in 88% of these 17 limbs and streptokinase (SK) and urokinase (UK) were equally effective. The dosage of SK varied between 50,000 and 150,000 units (seven patients) and of UK between 35,000 and 150,000 units (21 patients). Serum fibrinogen levels declined significantly after IIFT (t test; p less than 0.05), but the average level remained within the normal range. Major bleeding developed in two patients, both of whom received SK and underwent a concomitant major abdominal vascular procedure, with a severe fall in fibrinogen values to 10 and 17 mg/dl. A minor groin hematoma occurred in one patient treated with UK. There was a significant difference in the incidence of bleeding between SK (2/7) and UK (1/21) (chi 2; p less than 0.05). Compartment syndrome developed in six limbs (21%). Amputation was required in two patients (7%). There was no correlation between prolongation of ischemia time as a result of IIFT and the incidence of compartment syndrome.(ABSTRACT TRUNCATED AT 250 WORDS)