Vascular and Endovascular Surgery

In the thirty-six-month period after October 1, 1992, 20 patients were seen who experi enced profuse external hemorrhage from subcutaneous varicose veins or intracutaneous telangiectasias.

These were, for the most part, elderly, the 11 women averaging 68.9 years of age, and the 8 men (exclusive of a fourteen-year-old boy) averaging 58.6 years of age. None of the episodes of bleeding occurred in patients with venous ulcer, and trauma was not a factor in producing bleeding. The bleeding was characterized by high-pressure jet effect, which caused a fountain-like hemorrhage to occur. Hemorrhage was stopped by local pressure, and definitive treatment was by sclerotherapy, surgical removal of sources of venous hypertension, or combinations of these.

Continuous-wave Doppler evaluation assisted in selecting patients for surgery, and duplex ultrasound provided information that guided the surgical events.

A complete review of previously reported cases suggests this is a dangerous and not trivial complication of venous hypertension and varicosities. Suggested management is outlined.

The purpose of this prospective, randomized, double-blind investigation was to compare two different parenteral antibiotics (ampicillin/sulbactam and cefoxitin) in conjunction with appropriate surgical procedures for treatment of patients with diabetic foot infec tions on a vascular surgery service. Thirty-six patients with diabetes mellitus who required hospitalization to treat foot infections were randomized into one of two treatment groups. There were 18 patients with similar baseline characteristics random ized to each treatment group. The Chi-square test was used for clinical and bacteriolog ical comparisons, the Wilcoxon rank sum test was used for comparing duration of hospi talization and clinical signs and symptoms, and Fisher's Exact Test (two-tailed) was used to compare treatment outcomes of the two groups. Based on intention-to-treat analysis, there was no significant difference in treatment outcome (cure + improved) between the ampicillin/sulbactam (15/17) and cefoxitin groups (16/17). Similarly, no significant differences in bacteriologic response were noted. Both ampicillin/sulbactam and cefoxitin, when combined with appropriate surgical interventions, are safe and effective therapies for treating foot infections in patients with diabetes mellitus.

Clinical management of superficial thrombophlebitis has been guided by the assumption that this lesion is self-limited and rarely progresses to serious sequelae. This study eluci dates the fact that this lesion is frequently associated with deep venous thrombosis and potential pulmonary embolism. Accurate diagnosis requires the use of duplex scanning, and an appreciation of the natural history of this problem is essential to recommend treatment.

Many vasoconstrictor substances have been demonstrated as being vasodilators through the mechanism of endothelium-derived relaxing factor (EDRF)-nitric oxide (NO) release. The authors have hypothesized that all naturally secreted vasoconstrictor substances may potentially be vasodilators as well in order to maintain an adequate physiological vascular tone and have suggested a new term (vasoactivator) for vasoconstrictors. They have recently found that the vasoconstriction induced by a mimetic (U46619) of thromboxane A₂ (TXA₂), a naturally secreted vasoconstrictor substance released from platelets, may be markedly influenced by the presence of endothelium in the porcine coronary artery (PCA). This may be due to basal (spontaneous) release of EDRF (NO) or stimulated biosynthesis/release by thromboxane A₂. The present study was designed to further investigate whether stimulated release of EDRF (NO) by TXA₂ exists. PCA rings were mounted in organ baths under a physiologic pressure. The concentration-contraction curves to U46619 were compared in endothelium-intact (+E, n=7) and endothelium- denuded (—E, n=4) rings. At the maximal contraction induced by U46619 (-6.5 log M), NG-nitro-L-arginine (L-NNA, -4 log M) was added. In separate experiments, at resting condition, L-NNA (-4 log M) or U46619 (-7.7 log M) was added and the force changes were recorded. After twenty minutes, U46619 (-7.7 log M) or L-NNA (-4 log M) was added to study the force developed. U46619-induced contraction forces were signifi cantly higher in the -E rings at the concentrations of -9.5 to -7.5 log M and L-NNA induced further contractions in the +E (P < 0.01) but not in the -E rings. In resting conditions, L-NNA induced 0.12 g and further addition of U46619 (-7.7 log M) induced 8.8 g contraction force (P < 0.0001). On the other hand, U46619 (-7.7 log M) induced only 0.88 g contraction force whereas further addition of L-NNA induced a large force (7.43 g, P < 0.0001). The authors conclude that although basal release exists in the PCA this cannot explain the large difference between the +E arteries and the -E or L-NNA incubated arteries, and therefore, TXA₂ stimulates EDRF (NO) biosynthesis/release in the porcine coronary artery.

Hypothermia has been shown to have pathophysiological consequences on endothelial and smooth muscle cell functions. The impact of rewarming on vessels is unknown. This study examines the contractile functions of two sets of rabbit external jugular veins, the first after equilibration at 37°C and the second after cooling from 37°C to 20°C for one hour and following rewarming to 37°C. The pharmacologic parameters: Emax (the maximal response expressed as a ratio of the contraction to 60 mM KCl) and the EC₅₀ concentration, (which produces 50% of the maximal response ) were calculated. Nonreceptor-mediated contractile responses (KCl) did not significantly change with cooling or on rewarming. The sensitivity to norepinephrine increased, whereas the Emax decreased significantly on cooling to 20°C; both parameters returned to control levels on rewarming. Both the histamine sensitivity and Emax were decreased (P<0.05) with cooling. The Emax for histamine returned to normal on rewarming. In contrast to norep inephrine, the jugular vein sensitivity to histamine did not fully recover to untreated control values on rewarming. The sensitivity to bradykinin increased (P<0.05) with cooling and remained so on rewarming. The Emax for bradykinin decreased on cooling and dropped further upon rewarming (P < 0.05) . Thus, cooling produced a mixed pattern of alterations in response to contractile agonists, and rewarming did not result in a uniform restoration of these responses. These observations may have clinical implications for organ transplantation, for hypothermic surgery, and for individuals accidentally exposed to cold environmental conditions.

Chronic venous insufficiency (CVI) with associated venous hypertension may lead to stasis dermatitis and ulceration. This sixty-month study determined whether compliance with the use of below-the-knee graduated-compression hosiery affected long-term clinical manifestations.

At one year, 105 patients of 284 (37%) were compliant and 179 (63%) were not. At 2 years, of the available compliant patients (89), none had skin changes; 28% of the available (51) noncompliant patients had skin changes; and 13 of this group (51) had ulceration. At sixty months, of 79 compliant patients available, none had ulceration and 11 had stasis changes. Of noncompliant patients (119) available for assessment, 63 (53%) have chronic skin changes.

Compliance with the use of gradient compression below-the-knee stockings reduces the incidence of venous stasis disease and ulceration.

Aortic surgery in renal transplant patients introduces a complex problem. Various means to protect the transplant kidney under these circumstances have been described including ex vivo renal perfusion, in situ renal perfusion with aortoiliac shunt, in situ renal perfusion with a pump oxygenator, and axillofemoral bypass. The authors' experience with a temporary axillofemoral bypass to maintain perfusion of a renal transplant during aortothromboendarterectomy with patch angioplasty is described. They believe that the risks for injury to the transplant kidney are substantially reduced with maintenance of renal perfusion during aortic occlusion.

Popliteal venous aneurysms are rarely reported but represent a known source for pulmonary emboli. Early diagnosis with prompt excision of the aneurysm and venous reconstruction eliminate the embolic source and prevent long-term sequelae of venous stasis. The authors present the case of a twelve-year-old girl with Klippel-Trenaunay syndrome who presented with a massive pulmonary embolus. Magnetic resonance angiography defined a saccular aneurysm of the popliteal vein, which was confirmed by contrast venography. The patient underwent resection of the venous aneurysm and lateral venorrhaphy. This is the twenty-sixth report in the English-language literature of pulmonary embolism originating from a popliteal venous aneurysm, and the youngest patient to date.

Repair of distal renal artery aneurysms poses a significant threat to kidney salvage despite improved operative techniques described over the past decades. The authors describe the case of a seventy-one-year-old woman who presented with an enlarging right renal artery aneurysm located at the renal hilum involving the lobar arteries. Operative repair was accomplished by excision of the saccular posterior wall and reconstruction with a saphenous vein patch. The ischemia time was thirty-three minutes and her postoperative course was uneventful. She was discharged home on the fifth postoperative day with normal renal function, and the renal arteriogram demonstrated a technically successful operation. They review the current literature, and this case is put into perspective with the natural history, clinical course, and present treatment of renal artery aneurysms.

Congenital renal arteriovenous malformations (AVM) are rare, with approximately 50 cases reported in the English literature. Typically they are small (1-2 cm) and the majority present with gross hematuria. The authors report a case of a young woman with a 6 cm congenital renal AVM diagnosed during her first pregnancy when she presented with signs of hypertension. Hematuria and rupture of the AVM were not part of her clinical course and a subsequent partial nephrectomy was curative. A review of the English literature of congenital AVMs is presented.

This case report gives the long-term outcome of a patient undergoing reconstruction of the iliac vein with internal jugular vein interposition graft following trauma. A 51-year- old woman sustained a gunshot wound at the confluence of the right common, internal, and external iliac veins as well as injuries to the small and large bowel. The internal iliac vein was ligated and the external and common iliac vein was reconstructed with inter position internal jugular vein graft. The internal jugular vein was chosen because of the fecal contamination due to the enteric injuries and the equivalent size and endothelial ized surface of the conduit. The internal jugular vein interposition graft has maintained long-term patency. The patient has been followed for six years with no development of leg swelling or chronic venous valvular insufficiency.

This is a case report of a fifty-six-year-old, obese, corticosteroid-dependent asthmatic who presented with a pulsatile left thigh mass, left calf and foot swelling, and two block left calf claudication. Upon investigation, he was found to have a superficial femoral artery pseudoaneurysm compressing the superficial femoral vein causing a deep venous thrombosis (DVT) of the superficial femoral, popliteal, posterior tibial, and peroneal veins. The patient underwent lytic therapy for the DVT, followed by resection of the superficial femoral artery aneurysm and reconstruction of the superficial femoral artery. The cause of the superficial femoral artery pseudoaneurysm is undetermined, since he had no history of trauma, infection, or vascular intervention. Very few cases of superfi cial femoral artery aneurysm or pseudoaneurysms have been reported in the literature. This is a unique case owing to the presentation from DVT caused by compression of the surrounding venous structures.

In cases of arteriogenic impotence, penile angiography is often performed before penile revascularization. Evaluation of the inferior epigastric arteries is critical for preoperative planning, for use of the dominant vessel is preferred. Performance of penile angiography requires knowledge of the extensive variations of the penile arterial system. This case report describes an anatomical variation of both the inferior epigastric artery and the penile arteries. Failure to recognize this variation could have resulted in a failed penile revascularization if surgery had been performed.

Although rare, neurologic injuries associated with infrarenal aortic and iliac artery surgery are devastating and associated with high mortality and morbidity. The authors reviewed their ten-year experience with 738 infrarenal aortic and iliac artery aneurysm repairs, 341 aortoiliac bypasses for occlusive disease, and 15 reoperations for infected aortic prosthesis to identify patients who suffered lower extremity neurologic deficits. Three patients, all following ruptured aneurysms, suffered injuries to the lumbosacral plexus during the study period. No injuries to the spinal cord were diagnosed. These cases are described, and the diagnosis, prognosis, and potential etiologies and prevention are discussed.

A twenty-six-year-old man was involved in a farming accident, whereby a corn head from a combine fell on his legs. He was transported by air care to the emergency room approx imately seventy-five minutes after the accident. Upon examination the patient was alert with a pulse of 100/minute, blood pressure 116/80 mmHg, and respiratory rate 20/minute. There was an anterior dislocation of the left knee with a wound in the popliteal fossa measuring 8 x 6 cm. There was a normal palpable left femoral pulse, but distal pulses were detectable only by Doppler. There was no evidence of an expanding hematoma or bruit. He had a left-sided foot drop with a cold, pale foot with diminished sensation. Roentgenograms of the lower extremities revealed an anterior dislocation of the left knee without any associated fracture. The patient was taken urgently to the operating room, and under general anesthesia a reduction of the anterior dislocation of the left knee, with debridement and irrigation of the wound, was done followed by stabi lization of the knee with an external fixator. The patient had palpable left posterior tibial and dorsal pedis artery pulses following the reduction. Intraoperative arteriography under fluoroscopy was then performed via the left femoral route by the Seldinger technique. This revealed a 50% 5-cm-long smooth stenosis of the left popliteal artery with normal distal runoff. It was decided to manage the patient's popliteal artery injury nonoperatively with anticoagulation and in-hospital serial observations. Duplex examination of the left popliteal artery confirmed the arteriographic findings. The patient was given intravenous heparin therapy for three days followed by warfarin for three months and is currently taking aspirin (325 mg/day). A follow-up duplex examination at one week and at one, six, and fifteen months following the injury revealed a normal healed popliteal artery.

Traumatic knee dislocations have a well-known association with popliteal artery injuries. Because of a high amputation rate associated with missed or delayed diagnosis of popliteal artery injuries, early diagnosis and repair of such injuries is the standard of care.

The authors describe the nonoperative management of this injury and review the literature on this subject.