A.J.P. Sandison

Fatal Colonic Ischaemia after Stent Graft for Aortic Aneurysm

The development of new technology has led to renewed interest among both surgeons and radiologists in the treatment of infrarenal aortic aneurysms by endovascular techniques. Parodi and Palmaz pioneered the endovascular repair of aortic aneurysms using a straight stent graft. 1 Chuter et al. developed a means of deploying a bifurcated graft via the transfemoral route 2 and other series have been reported recently. 3 However, all new techniques have a learning curve. We report a case of fatal internal iliac artery embolism associated with insertion of a stent graft used to treat a symptomatic abdominal aortic aneurysm.

Endovascular repair of residual iliac artery aneurysms following surgery for ruptured abdominal aortic aneurysm.

Emergency repair of ruptured abdominal aortic aneurysm continues to have a high mortality. Such patients require expeditious operations to repair the ruptured segment rather than attempts to deal with all coexisting disease. The use of endovascular techniques obviates the need for open surgery to repair iliac aneurysms. We report two patients who, after successful repair of ruptured abdominal aortic aneurysms, had three iliac artery aneurysms treated successfully by embolisation in one case and percutaneous insertion of a self expandable stent graft in two cases. The issues that arise from such an approach are discussed with a review of the literature.

Recurrent coronary-subclavian steal syndrome treated by left subclavian artery stenting

The left internal mammary artery (LIMA) has better long-term patency rates than long saphenous vein grafts when used for coronary artery bypass surgery. 1 However, blood flow through it can be compromised by proximal disease in the left subclavian artery, resulting in recurrence of the symptoms of myocardial ischaemia. This has been termed the coronary-subclavian steal syndrome, and retrograde flow through the LIMA graft can be shown on coronary angiography. Various treatments have been used to correct this, including carotid-subclavian bypass, percutaneous transluminal angioplasty (PTA) and most recently, primary stenting. We describe a case initially treated with angioplasty, which recurred and eventually required percutaneous stenting with complete resolution of symptoms.

The results of routine primary closure in carotid endarterectomy.

PURPOSE OF STUDY The aims of this study were to determine the incidence of restenosis following carotid endarterectomy with primary closure of the arteriotomy and to observe the natural history of disease progression in the 1st postoperative year. METHODS The study group consisted of a consecutive series of 126 patients undergoing carotid endarterectomy. Duplex imaging was performed preoperatively and at 8 weeks, 6 months and 1 year postoperatively. RESULTS Five patients (4%) had a residual stenosis. At 12 months, the overall restenosis rate was 15%: 8.5% for males and 28.9% for females. None of these restenoses were symptomatic. There was no significant difference in the diameter of the internal carotid artery between male and female patients (U = 896, P = 0.60) and no significant difference in the diameter of the arteries that had restenosed at 12 months and those that had remained patent (U = 391, P = 0.33). CONCLUSIONS Carotid endarterectomy with primary closure is associated with a low incidence of restenosis in men, but not in women. Criteria for selective patching should consider both gender and vessel calibre.

Acute limb ischaemia due to paradoxical embolism from a long-term central venous catheter

Introduction all pulses in the right leg were easdy palpable. A source of arterial embolism was not clinically evident The use of indwelling central venous catheters for Emergency angiography showed an occlusion of the long-term access for therapeutic regimens is becoming mid-left common iliac artery extending to the mid increasingly common, and the complications asexternal iliac artery. The right common, external and sociated with these hnes are well recognised. Cominternal iliac arteries and the left femoral, popliteal plications associated with insertion include and proximal trifurcation arteries were reported as pneumothorax, haemothorax, inadvertent arterial entirely normal. The appearance strongly suggested puncture, cardiac tamponade, and catheter emarterial embolism. Thrombolysis was inappropriate, bolisation. Long-term problems encompass sepsis and as the left leg had developed a neurosensory deficit. venous thrombosis. Paradoxical embolism has not preThe left groin was explored under local anaesthesia viously been described originating from a central venand an embolectomy was attempted. Adequate inflow ous line. We report a case of acute lower limb ischaemia could not be established, and this was felt to be due occurrmg as a result of paradoxical ebolisation of to organisation of previous emboli. A femorofemoral thrombus arising from an indwelling central venous crossover graft was performed using a polytetracatheter, fluoroethylene graft which successfully revascularised the left leg. Abdominal ultrasonography and transthoracic echoCase Report cardiography both failed to identify an embolic source. Subsequent transoesophageal echocardiography re-

Successful Intraarterial Thrombolysis of an Ischemic Limb Four Days After Laparoscopic Cholecystectomy

Abstract Intraarterial thrombolysis is usually contraindicated after abdominal surgery because of the risk of bleeding. However, it is a highly effective treatment for embolic acute limb ischemia, particularly for clearing the distal vessels. We report a case in which intraarterial thrombolysis was safely used 4 days after laparoscopic cholecystectomy in a patient with an acutely ischemic leg due to embolus.

Inadvertent rupture of a composite vein graft by angioplasty

The superiority of vein over polytetrafluoroethylene (PTFE) as a bypass conduit for grafts ending below the knee makes it the material of choice for this purpose. When insufficient long saphenous vein is available, lengths of arm vein may be used as a satisfactory alternative to make a composite graft. This may cause confusion in subsequent graft surveillance programs as the arm vein segment may show different characteristics from the remainder of the graft. We report a case where a stenosis developed in the arm vein segment of a bypass graft which subsequently ruptured during balloon angioplasty with formation of a false aneurysm. This was due to the balloon size being selected on the basis of the size of the long saphenous vein section of the graft instead of the arm vein segment. Full communication between surgeon and radiologist must include complete details of all materials used in bypass grafts in order to avoid potentially disastrous results from angioplasty.