Creighton A. Hardin

Prognosis of nerve injuries incurred during acute trauma to peripheral arteries

Fifty-nine cases of civilian traumatic injury of peripheral arteries were analyzed to determine the frequency, site and mode of accompanying nerve injury. Fifty-one percent of the patients sustained concomitant injury to one or more peripheral nerves. Nerve injury was more common with trauma in the arm (71 percent of cases) than in the leg (32 percent of cases). LOss of an extremity due to failure of vascular repair occurred in 10 percent of the patients. In contrast, 44 percent of patients had some permanent functional impairment of an extremity because of associated nerve injury. The importance of nerve injury in peripheral vascular trauma is discussed and recommendations for management are presented.

Aortoiliac reconstruction combined with nonvascular operations

Seventy-six patients with aortoiliac reconstruction and associated intraabdominal procedures were compared with 445 patients with aortoiliac revascularization alone to provide information about the associated morbidity and mortality of adding a nonvascular procedure to aortic reconstruction. Patients with aortoiliac reconstruction for limb salvage had a significant increase in complications when an abdominal procedure was performed in association with aortoiliac reconstruction (66 percent versus 14 percent, p less than 0.01). Additionally, patients with elective aortoiliac reconstruction had a significant increase in mortality when an abdominal procedure was performed in addition to aortoiliac reconstruction (9 percent versus 3 percent, p less than 0.01). A small bowel obstruction and a pancreatic pseudocyst occurred as a direct result of the associated abdominal procedure. None of the deaths could be directly attributed to a concomitant abdominal procedure. The demonstration of an increase in morbidity and mortality with the addition of nonvascular procedures to aortoiliac reconstruction, even though certain subgroups of patients underwent aortic revascularization, suggest that the surgeon must carefully weigh the benefits and risks before combining vascular and nonvascular operations.

Traumatic vascular injuries: Methods and results of repair☆

Abstract An analysis of thirty-six civilian traumatic arterial injuries was performed to determine the frequency, site, and mechanism of injury. The mechanism of injury was evenly divided between penetrating (nineteen) and blunt injuries (seventeen). Blunt trauma from motor vehicle accidents and penetrating injuries from gunshot wounds accounted for approximately 85 per cent of the injuries. Four of fifteen repairs in lower extremity arterial injuries resulted in amputation. Prolonged ischemia and massive soft tissue injury were the major causes of amputation. Eleven upper extremity arterial injuries were repaired with return of distal pulses in ten patients whereas one patient required subclavian artery ligation after rupture of a saphenous vein graft repair. Approaches for exposure, means of repair, and results are discussed.

Revision of gastric bypass

In this series, 90.6 percent of the patients who had revision of their original gastric bypass for failure to lose satisfactory weight had a significant additional weight loss. The postoperative complication rate was 21.4 percent, and there were no postoperative deaths. After proper evaluation of the patient, revision of a gastric bypass may be undertaken with expectation of a satisfactory result and an acceptable rate of complications.

CERVICOCEPHALIC ANGIOGRAPHY FOR CEREBROVASCULAR INSUFFICIENCY

The radiological investigation of patients presenting with the symptoms and signs of cerebrovascular insufficiency has become an extremely important concern of neurologic services in many teaching hospitals because of the increasing number of such patients. This increase has been the result not only of the fact that in general our population is aging, but also of the greater awareness of this condition among the general medical population. Although in different institutions in the United States the radiologic investigation is performed by neurosurgeons, vascular surgeons or radiologists, in our experience since the vast majority of these patients are admitted to a neurologic service, it is only logical that the clinical neurologist carry out the complete investigation. In this Medical Center cervicocephalic arteriography has been performed by members of the neurology house staff under the supervision of senior residents and attending physicians and in close cooperation with the radiologists. The introduction of various methods for the visualization of the extracranial arteries has permitted a new approach in the attempt to understand the intracranial vascular dynamics. I t has also resulted in the necessity for reviewing and revising some older concepts regarding the role of anastomotic channels within the skull. Finally, it has raised some healthy questions about the frequently dogmatically held concepts of clinico-anatomic correlation. In a therapeutic sense, the ability to visualize in their entirety the four arteries providing the brain’s blood supply, has enabled the vascular surgeon to intervene, often dramatically, in the therapy and the prophylaxis of cerebrovascular syndromes. It is the purpose of this communication to report upon our experience with cervicocephalic angiography in 250 patients with cerebrovascular

Paraprosthetic-enteric fistula. Role of Preoperative endoscopy.

SummaryA case of paraprosthetic-enteric fistula occurring after aortic aneurysectomy and Dacron graft placement is reported. Two and one-half years after aneurysectomy, the patient presented with the problems of fever of obscure origin, arthralgias, and anemia. The diagnosis of paraprosthetic-enteric fistula was made preoperatively by endoscopy. The role of endoscopy in the evaluation of postaneurysectomy complications is emphasized.

Carotid Body Tumors and Aneurysms

* From the Department of Surgery, University of Kansas Medical Center, Kansas City, Kansas. Aneurysms of the carotid artery are rare when compared with their incidence in other major arteries. Thompson’ reported six aneurysms arising from the bifurcation, internal or carotid arteries. Most of these cases were treated by fascia latta or cellophane wrapping and arteriorrhaphy. Only one aneurysm was resected and replaced with an arterial homograft. Shea and co-workers2 ~ 3 described two cases of end-to-end anastomosis of the common to the internal carotid artery in a mycotic aneurysm and the repair of an operative injury to the carotid bifurcation. Nemir4 excised

Surgical Treatment of Extracranial Carotid Aneurysms With Excision and Arterial Restoration

* Department of Surgery, University of Kansas Medical Center Kansas City, Kansas Aneurysms of the carotid artery are uncommon. They do occur with enough frequency to be considered in the differential diagnosis of cervical and retropharyngeal masses. A collected review of 56 reported carotid aneurysms treated by excision and arterial restoration from 1953 to 1972 are listed in the text. Undoubtedly there were more carotid aneurysms operated upon but not reported. An additional eight operated cases of extracranial cervical carotid aneurysms

Effect of skin extracts on the viability of homologous skin grafts in mice.

The purpose of these experiments is an attempt to prolong the survival of homografted skin on heterozygous CFW mice which had received subcutaneous injections of homologous skin extracts. Kohde,’ Allen,2 and Billingham, and Medawar? have reported on skin extracts prepared from homologous skin in animals of various species in an attempt to prolong the life of transplanted homografts. The results are reported with divergent success. Rhodes’sl work on the survival of homografts influenced by skin extract injections is not described in sufficient detail to warrant critical analysis. Allen and associates* have reported that the survival time of homografts in rabbits was extended 16 days by “desensitization” of the recipient with specific donor antigen. I t should be noted that these workers used phenol as a preservative in the preparation of the skin extracts. Billingham and MedawaP reinvestigated the above report and showed that “the lifetime of skin homografts transplanted to rabbits may be prolonged by the injection of a weak solution of phenol in saline. This prolongation of life is probably due to a nonspecific reaction to stress.” These workers were unable to prolong the survival of skin homografts by the injection of phenol-free donor skin extracts into the recipient rabbi IS.

Surgical treatment of primary hyperparathyroidism

Our reported experience with ninety-seven hypercalcemic patients having resected adenomas with no recurrent hypercalcemia or hypocalcemia had led us to continue a conservative approach. Twelve patients with multiple parathyroid gland involvement proven by biopsy were treated with three and one-half gland resection and autotransplantation.