A New Modified Surgical Technique of In Situ Reverse Arterialization: Leaving the Distal Saphenous Side Branches Open of Nonreconstructable Ischemic Leg Leads to Full Recovery.

BACKGROUND: Arterialization of the foot veins in patients with ischemic foot usually result in excessive foot edema, wound infection, venous gangrene, long hospitalization duration, and a high rate of amputation. We herein present an improved method of foot revascularization via the superficial venous system by in situ reverse arterialization (ISRA) of the foot venous bed, leaving the distal saphenous side branches open. METHODS: A 69-year-old patient with toe wet gangrene and end-stage peripheral vascular disease with absence of foot target arteries underwent ISRA procedure, using the great saphenous vein, which was anastomosed end-to-side to the proximal superficial femoral artery. Only proximal saphenous tributaries were ligated until arterial flow reached the pedal superficial veins. RESULTS: Postoperatively, the foot regained normal pulsation over the superficial venous system. The patient did not experience foot edema. On-table subtraction angiography demonstrated arterial flow through the long saphenous and dorsal foot veins, with returned venous flow through the anterior and posterior tibial veins. Methoxyisobutylisonitrile scan conducted 4 weeks postoperatively demonstrated positive oxygen uptake of the pedal muscles, which was absent before surgery. Electron microscopy of the muscles at the level of the transmetatarsal amputation demonstrated regeneration of muscle tissue with mitosis 6 weeks postoperatively. During 1,000 days of follow-up postsurgery, the flow was reduced and the transcutaneous pO2 level of the foot increased up to 76 mm Hg. CONCLUSIONS: This new modified surgical technique of ISRA, in which only proximal saphenous tributaries were ligated in order to prevent high systemic pressure in the foot venous low pressure system, resulted in increased levels of transcutaneous pO2 and reduced flow, leading to full recovery of the ischemic foot.

[Is there a role for asymptomatic carotid artery stenosis screening?].

Screening for asymptomatic carotid artery stenosis (CAS) is highly controversial Many surgeons routinely screen their patients for carotid disease prior to major operations, yet the benefit of such practice was never demonstrated. The treatment of symptomatic patients has not changed much during the last twenty years, since the publication of the North American Symptomatic Carotid Endarterectomy Trial (NASCET). However, in contrast, the Asymptomatic Carotid Atherosclerosis Study (ACAS) and the Asymptomatic Carotid Surgery Trial (ACST) failed to get the same acceptance among the multidisciplinary group treating CAS.The prevalence of asymptomatic 60-99% carotid artery stenosis among the general population is about 1%. Neither ACAS nor ACST showed that stenosis severity was associated with increasing stroke risk. The 'realpolitik' is that mass interventions in asymptomatic patients will probably only ever prevent about 1% of all strokes. This is even truer regarding patients scheduLed for major operation, in which the incidence of stroke is less than 1%. Moreover the current evidence in the literature suggests that the best medicaL treatment (BMT) results in 0.5% strokes per year, better than resuLts which can be offered by surgery. According to the current evidence, it seems that asymptomatic carotid artery screening should be discontinued, since it is a major waste of resources.

[Lymphedema--guidelines for evaluation and treatment].

Lymphedema is the "neglected vascular disease". A lot has been written about arterial and venous pathologies but our knowledge, as physicians, about the pathophysiology on the one hand and about the treatment, on the other hand, is scarce. Lymphedema is subdivided into primary and secondary disease. The primary lymphedema is further subdivided to congenital, praecox and tarda. Conservative treatment is the first line of therapy. Surgery has not been proven as a good solution for this disease, and furthermore, even when operations are being conducted, conservative treatment should be continued on a daily basis. It seems that further research about this "forgotten disease" should be designed in order to improve the treatment of these complicated patients.

[Secondary lymphedema--the importance of a multidisciplinary team approach].

Secondary lymphedema is the most common type of lymphedema. Malignancy, mainly breast carcinoma, is the main cause of upper extremity lymphedema, while groin dissection, irradiation and trauma are the cause of lower extremity lymphedema. Early recognition of the pathology followed by early referral to a vascular surgeon, leading a multidisciplinary team, who takes care of those patients, can prevent a miserable Life from these patients. Lifelong commitment of the patients, prolonged financial support of the health insurance supplier, as well as team work of the group taking care of the patient, is the only way to help these patients.

Epithelioid hemangioendothelioma as a rare cause of blue toe syndrome.

Blue toe syndrome (BTS), is a well-known entity of toe gangrene and rest pain secondary to micro emboli lodged within the digital arteries. BTS among young patients should alert physicians to look for causes such as trauma, connective tissue disease, hypercoagulability state, and others. We hereby describe a 32-year-old female with right BTS. A mass obstructing 80% of the right popliteal artery lumen was the source of emboli. The histologic results of the replaced arterial segment revealed a thrombus on top of epithelioid hemangioendothelioma. This is the first description of the association between primary vascular tumor and BTS.

Splenic artery aneurysms during pregnancy: An obstetric nightmare.

OBJECTIVE: In this study we report our experience in the management of Splenic Artery Aneurysm (SAA), diagnosed during pregnancy. STUDY DESIGN: The current manuscript describes three different events, treated in out our department, involving SAAs diagnosed during pregnancy. Each case presents an unusual course and a unique clinical challenge. RESULTS: The first case is of a 25 week's gestation twin pregnancy with ruptured SAA ending in maternal and fetal death. Another case of SAA rupture presented at 27 week's gestation with consequent emergency cesarean section and splenectomy. In the last case, two SAAs were incidentally diagnosed at 25 weeks' singleton gestation. The patient was managed conservatively and delivered by an elective cesarean section at 34 weeks followed by postpartum angiographic embolization of the aneurysms. CONCLUSIONS: Health care providers and especially obstetricians should be aware of the diagnosis of ruptured SAA in a pregnant woman with abdominal discomfort and hemodynamic deterioration. In addition, once an asymptomatic pregnant patient is diagnosed with a SAA, conservative surveillance may be allowed.

Endovascular Electrical Stimulation - A Novel Hemorrhage Control Technique.

OBJECTIVE: In this study we present a novel approach for inducing vasoconstriction by pulsed electrical treatment delivered via endovascular electrodes, which can be used in cases where external access to the vessel is limited. METHODS: Using computer simulations, we optimized various geometries of endovascular electrodes to maximize the induced electric field on the arterial wall. Using the optimal configuration parameters, we investigated endovascular induced vasoconstriction in both the carotid and femoral sheep arteries. RESULTS: Endovascular electrodes induced robust vasoconstriction in the carotid artery of sheep, showing gradual recovery following treatment. Moreover, the obtained vasoconstriction was accompanied by a sevenfold decrease in blood loss for 100% constriction, compared with no treatment (6ml vs 42ml, p<0.001). The femoral artery was less amenable to the electrical treatment, which we hypothesize results from the reduced density of the sympathetic system's innervation of the adventitia of the sheep femoral artery, as was validated by immunohistochemical analysis. Finally, treatment safety was validated through arterial histological studies, in which no adverse effect was observed, and through computer modeling, which depicted a negligible temperature increase. SIGNIFICANCE: These results are an important step toward developing a novel approach for inducing reversible and controlled vasoconstriction in arteries that are remote from access.

Effect of hemodialysis access blood flow on cardiac events after coronary artery bypass grafting using an internal thoracic artery.

BACKGROUND: The possibility of coronary steal through an arteriovenous fistula (AVF) in hemodialysis (HD) patients with coronary artery bypass grafts (CABGs) using an ipsilateral internal thoracic artery (ITA) has been suggested. In order to define the significance of such a possibility, we analyzed cardiac events and mortality risk in patients in relation to AVF flow. METHODS: A retrospective cohort study was performed on prevalent HD patients from a single center. The outcomes included a first cardiac event, cardiac death and death from any cause. RESULTS: The group consisted of 23 chronic HD patients having ITA CABG and upper extremity AV access, 12 patients had an ipsilateral and 11 patients had a contralateral location of ITA CABG and an upper extremity AV access. The mean follow-up period was for 37.0 months.Multivariable Cox proportional-hazards regression analysis of risk of death from any cause in relation to AV access flow showed no increased risk, neither in the group with ipsilateral location of ITA grafts and dialysis accesses (adjusted HR, 3.047 [95% CI, 0.996 to 1.000], p = 0.081), nor in the group with contralateral location of both shunts (adjusted HR, 0.173 [95% CI, 0.997 to 1.002], p = 0.678). There was no significant correlation between AV access blood flow and the risk of first cardiac event as well as cardiac death in either study group. CONCLUSIONS: In this study on HD patients having ipsilateral ITA CABG and AVF, fistula flow rate was not found to be associated with mortality or cardiac risk.

Civilian casualties of terror-related explosions: The impact of vascular trauma on treatment and prognosis.

OBJECTIVES: A high prevalence (10%) of vascular trauma (VT) was previously described in terror-related trauma as compared with non-terror-related trauma (1%), in a civilian setting. No data regarding outcome of VT casualties of improvised explosive device (IED) explosions, in civilian settings, are available. The aim of the current study is to present the prognosis of civilian casualties of IED explosions with and without VT. METHODS: A retrospective analysis of the Israeli National Trauma Registry was performed. All patients in the registry from September 2000 to December 2005 who were victims of explosions were included. These patients were subdivided into patients with VT (n = 109) and non-VT (NVT) (n = 1,152). Both groups were analyzed according to mechanism of trauma, type and severity of injury, and treatment. RESULTS: Of 1,261 explosion casualties, there were 109 VT victims (8.6%). Patients with VT tended to be more complex, with a higher injury severity score (ISS): 17.4% with ISS 16 to 24 as compared with only 10.5%. In the group of critically injured patients (ISS, 25-75), 51.4% had VT compared with only 15.5% of the NVT patients. As such, a heavy share of hospitals' resources were used-trauma bay admission (62.4%), operating rooms (91.7%), and intensive care unit beds (55.1%). The percentage of VT patients who were admitted for more than 15 days was 2.3 times higher than that observed among the NVT patients. Lower-extremity VT injuries were the most prevalent. Although many resources are being invested in treating this group of patients, their mortality rate is approximately five times more than NVT (22.9% vs. 4.9%). CONCLUSIONS: Vascular trauma casualties of IED explosions are more complex and have poorer prognosis. Their higher ISS markedly increases the hospital's resource utilization, and as such, it should be taken into consideration either upon the primary evacuation from the scene or when secondary modulation is needed in order to reduce the burden of the hospitals receiving the casualties. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level V.

Mass medical repatriation of injured civilians after terrorist attack in Mombassa, Kenya: medical needs, resources used, and lessons learned.

INTRODUCTION: On 28 November 2002, three suicide bombers crashed their car into a hotel in Mombassa, Kenya; 12 people were killed, including three Israelis, and 80 were wounded (22 of whom were Israeli). The Israeli Defense Force Airborne Medical Evacuation Flight Teams participated in a repatriation mission to bring the wounded home. OBJECTIVES: The objectives of this study are to outline the distinctive aspects of this mission, as well as to share the experiences and lessons learned. METHODS: Israeli Army debriefing reports were used to study the composition of the crew, medical equipment taken, injury distribution, mode of operation, and mission schedule. RESULTS: A total of six fixed-wing aircraft were used--two Boeing 707s and four Hercules C-130s--with a total of 54 medical team members on board. A total of 260 Israelis were repatriated, 22 of whom were wounded, and three were dead. Of the casualties, 14 were conveyed sitting, and eight supine. The time from the first landing in Kenya to the evacuation of the last supine patient was 5.5 hours. Nurses, as well as social workers, played a central role in the mission. A forward team, including five doctors, was used for the initial organization and for gathering information on the medical status of the casualties. CONCLUSIONS: There was redundancy in the medical crew and medical equipment sent. The need for improved infrastructure on the medical aircraft was stressed. Based on this experience, a new mode for operation for similar missions in the future was formulated.

Evaluating new types of tourniquets by the Israeli Naval special warfare unit.

BACKGROUND: Extremity injuries, which accounts for 20% of all battlefield injuries, result in 7-9% of deaths during military activity. Silicone tourniquets were used, by the Israeli Defense Force (IDF) soldiers, for upper extremity and calf injuries, while thigh injuries were treated by an improvised "Russian" tourniquet (IRT). This is the first study, performed in the IDF, comparing the IRT with Combat Application Tourniquets (CAT) and Special Operations Force Tactical Tourniquets (SOFTT). 23 operators from the Israeli Naval Unit (Shayetet 13) were divided into two groups according to their medical training (11 operators trained as first-responders; 12 operators as medics). Repetitive applications of the three tourniquets over the thigh and upper arm, and self-application of the CAT and SOFTT over the dominant extremity were performed using dry and wet tourniquets (828 individual placements) with efficacy recorded. Cessation of distal arterial flow (palpation; Doppler ultrasound) confirmed success, while failure was considered in the advent of arterial flow or tourniquet instability. Satisfaction questionnaires were filled by the operators. RESULTS: CAT and SOFTT were found to be superior to the IRT, in occluding arterial blood flow to the extremities (22%, 23% and 38%, respectively, failure rate). The application was quicker for the CAT and SOFTT as compared to the IRT (18, 26, 52 seconds, respectively). Wet tourniquets neither prolonged application nor did they increase failure rates. Similarly, medics didn't have any advantage over non-medic operators. No findings indicated superiority of CAT and SOFTT over one another, despite operators' preference of CAT. CONCLUSIONS: CAT and SOFTT offer an effective alternative to the IRT in stopping blood flow to extremities. No difference was observed between medics and non-medic operators. Thus, the CAT was elected as the preferred tourniquet by our unit and it is being used by all the operators.

A vasoactive intestinal peptide receptor analog alters the expression of homeobox genes.

A lipophilic analog of vasoactive intestinal peptide (VIP), stearyl-Nle(17)-neurotensin(6-11)VIP(7-28) (SNH), that inhibited lung cancer growth, has been previously described. The mechanism of SNH inhibition of cancer growth is still being elucidated. The present study examined the effects of SNH on homeobox genes in the colon cancer cell line HT 29 that expresses VIP receptors. Homeobox genes contain a characteristic DNA sequence, coding for a stretch of 61 amino acid homeodomain that binds specific DNA motifs. While the HOX gene family contains a single homeodomain, the POU gene family contains an additional DNA binding homeodomain. HT 29 cells were incubated with SNH; RNA was extracted and subjected to reverse-transcription-polymerase chain reaction (RT-PCR) with primers that matched the conserved area of the various HOX or POU genes. The PCR products that were altered by SNH treatment were sequenced. Three candidate SNH-responsive genes, the HOX A4, the HOX B5 and the PUO V transcription factor I (Oct-3) were identified. Semi-quantitative RT-PCR with specific primers confirmed the increase in HOX A4 and the decrease in Oct-3 expression levels following SNH treatment. Thus, the HOX A4 and the Oct-3 homeobox genes may partially mediate SNH activity on cancer cells.

Rectal cancer: the impact of a colorectal unit on the preservation of the anal sphincter.

BACKGROUND: Mid- and lower rectum cancer is a technical challenge to the surgeon aiming to preserve the anal sphincter. The choice between abdominoperineal resection and anterior resection is often related to surgical skills. OBJECTIVES: To evaluate the role of a specialized colorectal unit in preserving the anal sphincter mechanism in the treatment of rectal cancer. METHODS: Between 1991 and 1996, 75 patients with rectal cancer up to 12 cm from the anal verge were operated at the Sheba Medical Center. Among them, 21 patients (group 1) underwent surgery in the colorectal unit and 54 patients (group 2) in the other two surgical departments. All patients had a complete preoperative investigation and were followed for 12-90 months. RESULTS: Background and tumor parameters were similar for both groups. In group 1, 20 patients (95%) had low anterior resection and 1 patient (5%) had abdominoperineal resection as compared to 20 patients (37%) and 34 patients (63%), respectively, in group 2 (P < 0.005). There was no statistical difference in the systemic recurrence rate. Local recurrence was more frequent in group 2 (P < 0.05). CONCLUSIONS: Special training in colorectal surgery enables the surgeon, in keeping with the principles of oncologic surgery, to preserve the anal sphincter mechanism in most patients with adenocarcinoma located in the mid- and lower third of the rectum.

Terror attacks increase the risk of vascular injuries.

OBJECTIVES: Extensive literature exists about military trauma as opposed to the very limited literature regarding terror-related civilian trauma. However, terror-related vascular trauma (VT), as a unique type of injury, is yet to be addressed. METHODS: A retrospective analysis of the Israeli National Trauma Registry was performed. All patients in the registry from 09/2000 to 12/2005 were included. The subgroup of patients with documented VT (N = 1,545) was analyzed and further subdivided into those suffering from terror-related vascular trauma (TVT) and non-terror-related vascular trauma (NTVT). Both groups were analyzed according to mechanism of trauma, type and severity of injury and treatment. RESULTS: Out of 2,446 terror-related trauma admissions, 243 sustained TVT (9.9%) compared to 1302 VT patients from non-terror trauma (1.1%). TVT injuries tend to be more complex and most patients were operated on. Intensive care unit admissions and hospital length of stay was higher in the TVT group. Penetrating trauma was the prominent cause of injury among the TVT group. TVT group had a higher proportion of patients with severe injuries (ISS ≥ 16) and mortality. Thorax injuries were more frequent in the TVT group. Extremity injuries were the most prevalent vascular injuries in both groups; however NTVT group had more upper extremity injuries, while the TVT group had significantly much lower extremity injuries. CONCLUSION: Vascular injuries are remarkably more common among terror attack victims than among non-terror trauma victims and the injuries of terror casualties tend to be more complex. The presence of a vascular surgeon will ensure a comprehensive clinical care.

Clostridium septicum post-endovascular aneurysm repair stent-graft infection.

Endovascular aortic aneurysm repair (EVAR) is establishing its role as a valid alternative for the treatment of abdominal aortic aneurysm. Post-EVAR graft infection is a rare and devastating complication. The incidence of post-EVAR graft infection is yet to be defined, and available data at this stage consist of case reports and small series. Possible etiologies for aortic stent-graft infection include perioperative contamination and hematogenous seeding. To the best of our knowledge, this is the first report of post-EVAR stent graft infection with Clostridium septicum. The possible mechanisms of this unusual hematogenous seeding have been discussed.