RESUMO
Congenital anomalies of the inferior vena cava (IVC), although rare, are a risk factor for lower limb deep venous thrombosis (DVT). A 19-year-old male presented with a left flank and groin pain caused by iliofemoral venous thrombosis. Vascular imaging by computed tomography (CT) scanning and venography demonstrated agenesis of the IVC. Catheter-directed thrombolysis via a popliteal vein was attempted but did not alter the patency of the common femoral vein outflow collaterals into the retroperitoneal azygous venous system. The patient was anticoagulated using systemic heparin infusion and clinical symptoms resolved within 5 days. He was transitioned to oral Coumadin anticoagulation, and follow-up venous duplex testing demonstrated no infrainguinal DVT and phasic venous flow with respiration in the femoral vein indicating patent collateral veins. Anomalies of the IVC are present in 0.3-0.5% of otherwise healthy individuals. Agenesis of the IVC has an incidence of 0.0005-1% in the general population but is found in almost 5% of patients <30 years of age with unprovoked lower limb DVT. In adults, IVC agenesis anomaly can cause diagnostic problems in the paravertebral area because of the tumor-like appearance of the azygous venous collaterals on noncontrast CT imaging. In young adults presenting with unprovoked lower limb DVT, the presence of an IVC anomaly should be considered and evaluated for by venous duplex testing and if necessary CT venography.
Assuntos
Malformações Vasculares/complicações , Veia Cava Inferior/anormalidades , Trombose Venosa/etiologia , Humanos , Masculino , Flebografia , Tomografia Computadorizada por Raios X , Ultrassonografia Doppler Dupla , Malformações Vasculares/diagnóstico , Trombose Venosa/diagnóstico , Adulto JovemRESUMO
A 19-year-old woman underwent an ileoanal pull-through. Intraoperatively, deepening of anesthesia was associated with reduced bleeding. Therefore, induced hypotension, mean arterial blood pressure 50 to 55 mm Hg, was maintained for 2.5 hours. Postoperatively, the patient was paraplegic with spinal cord infarction on magnetic resonance imaging from T9 to the tip of the conus medullaris. The collateralization of the anterior spinal artery is very variable and it seems likely that in this individual induced hypotension was associated with inadequate blood flow in the distribution of the artery of Adamkiewicz.
Assuntos
Pressão Sanguínea , Colo/cirurgia , Hipotensão/etiologia , Ileostomia/efeitos adversos , Isquemia do Cordão Espinal/etiologia , Medula Espinal/irrigação sanguínea , Anestesia Geral/efeitos adversos , Perda Sanguínea Cirúrgica/prevenção & controle , Feminino , Humanos , Hipotensão/complicações , Hipotensão/fisiopatologia , Paraplegia/etiologia , Paraplegia/fisiopatologia , Fluxo Sanguíneo Regional , Isquemia do Cordão Espinal/diagnóstico , Isquemia do Cordão Espinal/fisiopatologia , Tomografia Computadorizada por Raios X , Adulto JovemRESUMO
We present the case of a young man active duty in the military who initially presented with pelvic pain and fullness during sexual activity. Extensive workup showed a large pelvic arteriovenous malformation (AVM). He underwent over 10 interventional radiology procedures to embolise his AVM and suffered multiple postoperative complications resulting in exploratory laparotomies, bowel resections and ultimately a colostomy. Six years after his embolisation procedures, he was found on imaging to have gluteal fluid collections with metallic particles, presumed to be migrated Onyx from his angioembolisations as a result of non-target embolisation. Current literature does not document other instances of Onyx material migrating from an intravascular source to interstitial tissue.
Assuntos
Embolização Terapêutica , Malformações Arteriovenosas Intracranianas , Embolização Terapêutica/métodos , Humanos , Malformações Arteriovenosas Intracranianas/terapia , Masculino , Complicações Pós-Operatórias , Resultado do TratamentoRESUMO
PURPOSE: To evaluate a unique method of extended mentorship in robot-assisted laparoscopic prostatectomy (RALP) at VA San Diego Healthcare System (VASDHS). As novel robotic technologies diffuse into surgical practice, developing safe apprenticeships remains a challenge. PATIENTS AND METHODS: Between October 2008 and November 2010, 90 RALPs were prospectively divided into three phases: Proctored, Independent, and Instructor. During the first 30 Proctored cases, an experienced robotic surgeon from the affiliated university-based hospital mentored a robotic novice attending surgeon with previous open retropubic and laparoscopic experience. The novice surgeon gained proficiency during the next 30 Independent cases, then introduced increasing resident participation during the last Instructor 30 cases. Patient demographics, tumor characteristics, operative measures, and length of hospital stay were compared. Functional outcomes were assessed using the Sexual Health Inventory for Men and an incontinence questionnaire. We used independent t test, analysis of variance, Mann-Whitney U test, Fisher exact test, Kruskal-Wallis, and Pearson chi-square tests for comparison in these patient populations. RESULTS: All groups were similar in age, clinical T-stage, and D'Amico Risk Group. Preoperative prostate-specific antigen levels were significantly higher (P<0.001) and prostates were larger (P=0.044) in the middle Instructor Phase. The early Proctored Phase had the lowest Gleason scores and the lowest body mass indexes. Despite these differences favoring the Proctored Phase, immediate operative outcomes were similar with respect to safety, oncologic, and functional parameters. CONCLUSIONS: In the VASDHS cohort, RALPs were performed safely under the supervision of a newly proctored attending surgeon. Although longer follow-up could reveal subtle differences between groups, overall follow-up was similar to most existing studies. Extended mentorship by an experienced surgeon is a viable model for achieving proficiency in RALP in a setting such as a VA hospital affiliated with an academic hospital and increasing access to care for the veteran patient population.
Assuntos
Prostatectomia/educação , Neoplasias da Próstata/cirurgia , Procedimentos Cirúrgicos Robóticos/educação , Idoso , Análise de Variância , Distribuição de Qui-Quadrado , Humanos , Tampões Absorventes para a Incontinência Urinária/estatística & dados numéricos , Laparoscopia/métodos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Prostatectomia/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Estatísticas não Paramétricas , Resultado do Tratamento , Incontinência Urinária , VeteranosRESUMO
HYPOTHESIS: Assessment and remedial clinical education of practicing surgeons is feasible and possibly beneficial. DESIGN: Retrospective series. SETTING: Urban academic medical center. PARTICIPANTS: Licensed surgeons. INTERVENTIONS: Structured assessment and remedial clinical education based on resident-education models. MAIN OUTCOME MEASURES: Assessment and clinical education results. RESULTS: Forty-seven general, general/vascular, and colorectal surgeons were assessed by the University of California, San Diego, Physician Assessment and Clinical Education program in 2000 to 2010. Forty-six (98%) were male (mean [SD] age, 54 [11] years; range, 34-80 years). Thirty-three (70%) came from state medical board actions: 25 from California's disciplinary division, 2 from California's licensing division, 3 from other state boards, and 3 self-referred during other state board actions. Fourteen (30%) came from health care organizations: 8 from California hospitals, 3 from hospitals in other states, 2 self-referred during hospital proceedings, and 1 self-referred during a medical group investigation. Twenty-three (49%) underwent a 2-day assessment only, including a 1-hour mock oral board examination: 8 "passed" with no recommendations; 6, with minor recommendations; 6 had major recommendations; and 3 "failed." Twenty-four surgeons (51%) also completed 26 five-day clinical education programs, with 20 "passes," 1 minor recommendation, 3 major recommendations, and 2 "fails." CONCLUSION: A program of assessment and remedial clinical education of surgeons designed to meet the needs of one medical board is being used by nongovernmental organizations as well, and it seems to meet the needs of some individual surgeons. This type of program may play a role in the profession's self-regulation.
Assuntos
Competência Clínica/normas , Cirurgia Geral/educação , Ensino de Recuperação , Conselhos de Especialidade Profissional , Centros Médicos Acadêmicos , Adulto , Idoso , Idoso de 80 Anos ou mais , California , Estudos de Viabilidade , Feminino , Médicos Graduados Estrangeiros/normas , Humanos , Licenciamento em Medicina , Masculino , Pessoa de Meia-IdadeRESUMO
A 62-year-old man presented with several months of progressive hemoptysis. He has a history of aortobifemoral bypass and thoracofemoral bypass grafts, which were both removed due to infection. Evaluation with multiple imaging modalities revealed a descending thoracic aortic pseudoaneurysm around the retained Dacrontrade mark graft with bronchiectatic changes and consolidation of the adjacent left lower lobe. No evidence of direct arterial communication between the aorta and the bronchioles was ever demonstrated, but an aortopulmonary fistula was suspected. Endovascular repair with several Excluder aortic cuffs stacked in the thoracic aorta was successfully performed via the axillary artery. Exclusion of the pseudoaneurysm with no evidence of endoleak was noted on computed tomography 2 months postoperatively, at which time the patient reported complete resolution of his hemoptysis. To our knowledge, this is the first report of endovascular repair of an aortopulmonary fistula via the axillary artery.
Assuntos
Implante de Prótese Vascular , Aneurisma da Aorta Torácica/diagnóstico por imagem , Artéria Axilar , Implante de Prótese Vascular/métodos , Progressão da Doença , Hemoptise/etiologia , Humanos , Angiografia por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Tomografia Computadorizada por Raios XRESUMO
Lower extremity venous insufficiency is a highly prevalent condition. Now it is understood that telangiectasias, reticular varicosities, and true varicose veins are physiologically similar and etiologically identical. The four main influences causing these abnormalities are heredity, female sex, gravitational hydrostatic forces, and hemodynamic muscular compartment pressure. There are clear indications and goals for intervention. A cornerstone in the treatment of venous insufficiency is elimination of sources of venous hypertension. One of these is the refluxing greater saphenous vein. Minimally invasive saphenous ablation can be achieved by radiofrequency energy and laser light energy. These new techniques eliminate the psychologic barrier to treatment caused by the term "stripping" and allow the objectives of surgery to be achieved with minimal invasion and quick recovery. Endovenous techniques show great promise. They provide minimal invasion, often under local anesthesia and intravenous sedation, thereby eliminating the need for general anesthesia. Objectives of venous insufficiency have been established and the endoluminal minimally invasive techniques developed in recent years appear to accomplish their goals.
Assuntos
Extremidade Inferior/irrigação sanguínea , Insuficiência Venosa/cirurgia , Insuficiência Venosa/terapia , Ablação por Cateter , Feminino , Seguimentos , Humanos , Veia Safena/fisiopatologia , Veia Safena/cirurgia , Varizes/cirurgia , Varizes/terapiaRESUMO
Carotid artery angioplasty with stenting (CAS) is being increasingly used in the treatment of extracranial carotid artery stenosis. As in other catheter-based approaches to the treatment of arterial disease, surgical intervention may be required because of either acute complications or correct critical restenosis. We have reviewed our experience managing early complications and critical in-stent restenoses after CAS in a tertiary care university hospital and a Veterans Affairs Medical Center. During the last 5 years, 22 carotid arteries (21 patients) underwent CAS. One patient developed thrombosis and rupture of the carotid artery during stenting. Two other patients (3 arteries) developed critical restenosis within 12 months. Subsequent surgical reconstructions included an internal carotid artery (ICA)-to-external carotid artery (ECA) transposition and a common carotid artery (CCA)-to-ICA bypass with reversed saphenous vein (RSV). The patient who underwent CCA-to-ICA bypass later required subclavian-to-ICA bypass because of rapidly progressive intimal hyperplasia and subsequent occlusion of the CCA. The other patient has not had surgical repair because of his deteriorating condition and significant co-morbidities. During the same time period, two additional patients were referred from outside institutions specifically for surgical intervention after carotid stenting. One had delayed rupture of the carotid artery 1 day after stenting and underwent urgent surgical repair. Another patient had early, critical restenosis within the stent and underwent placement of a CCA-to-ICA interposition graft using RSV. Acute treatment failures after CAS can be successfully managed using standard surgical techniques. Patients who develop critical in-stent restenosis requiring surgical repair may need more challenging surgical reconstructions to maintain cerebral perfusion.
Assuntos
Angioplastia com Balão , Artéria Carótida Externa/cirurgia , Artéria Carótida Interna/cirurgia , Estenose das Carótidas/terapia , Stents , Idoso , Angioplastia com Balão/efeitos adversos , Artéria Carótida Externa/diagnóstico por imagem , Artéria Carótida Interna/diagnóstico por imagem , Estenose das Carótidas/diagnóstico por imagem , Endarterectomia das Carótidas , Humanos , Masculino , Pessoa de Meia-Idade , Radiografia , Recidiva , Estudos Retrospectivos , Falha de Tratamento , Ultrassonografia Doppler DuplaRESUMO
Reduction in the thrombogenicity of small-caliber synthetic vascular grafts by lining them with mesothelial cell has been suggested as a method to reduce thrombosis. The purpose of this research is to determine whether creation of a mesothelial lining on the inner surface of a synthetic vascular graft would improve the patency rate of a small-caliber vascular grafts. Carotid interposition grafting was performed using mesothelial-lined grafts (MLG) in 30 New Zealand rabbits and compared with similar carotid interposition grafts using non-mesothelial-lined grafts (NLG) on the contralateral side. The mesothelial lining was created by suturing a piece of harvested peritoneum with the visceral surface toward the lumen onto a 2-mm polytetraflouroethylene (PTFE) graft. Graft patency was studied by in vivo Dopler. In vitro evaluations were done with hematoxylin-eosin stains, broadband cytokeratin staining, and monoclonal antibodies for macrophages. Explanation of the grafts was done in terminal operation at 7, 14, and 21 days. The MLG showed progressive fibroblastic proliferation in direct proportion to the age of the graft, but this did not lead to graft occlusion. However, a significant number of NLG were not patent at each time period studied. We concluded that mesothelial cell lining of smallcaliber PTFE grafts could enhance the short-term patency more than using the PTFE without the mesothelial lining. The use of such hybrid small-caliber grafts has a potential for improving the patency of these artificial vascular graft substitutes.
Assuntos
Prótese Vascular , Endotélio/citologia , Epitélio/patologia , Oclusão de Enxerto Vascular/prevenção & controle , Peritônio/citologia , Politetrafluoretileno/uso terapêutico , Trombose/prevenção & controle , Animais , Prótese Vascular/efeitos adversos , Endotélio Vascular/citologia , Oclusão de Enxerto Vascular/etiologia , Masculino , Modelos Animais , Politetrafluoretileno/efeitos adversos , Desenho de Prótese , Coelhos , Trombose/etiologia , Ultrassonografia DopplerRESUMO
Blue toe syndrome commonly occurs as a result of aneurysmal or atherosclerotic disease in the iliac arteries. Surgery, angioplasty, or intraarterial stent placement are the most common treatment options but the optimal management has not been defined. Here we report managing distal microembolization from iliac artery atherosclerosis associated with aneurysmal dilation with the Wallgraft Endoprosthesis, a self-expanding metallic stent covered with Dacron. Three common iliac arteries in two patients were treated using this device. A 79-year-old male presented with unilateral symptoms and an 83-year-old female with bilateral disease. Arteriography demonstrated complex plaque at the aortic bifurcation associated with aneurysmal dilation of the distal common iliac artery in both patients. This complex disease was successfully covered using the Wallgraft Endoprosthesis. Postoperatively the patients received aspirin, their toe lesions healed, and neither has had a recurrence after 16 months. Covered stents offer the theoretic advantage of completely excluding the diseased segment, preventing the escape of thrombus or plaque debris, and covering aneurysmal dilation in the artery.