David L. Harshfield

Thromboembolism in patients undergoing thoracotomy

To determine the incidence of thromboembolism in relation to thoracotomy, 77 patients undergoing pulmonary resection were prospectively studied up to 30 days postoperatively for deep venous thrombosis and pulmonary embolism. Overall, 20 of 77 patients (26%) had thromboembolic events during their hospitalization. Four deep venous thromboses and 1 pulmonary embolism were detected in 5 of 77 patients preoperatively for an incidence of 6%. Postoperative thromboembolism was detected in 15 of 77 (19%): deep venous thrombosis in 11 (14%) and pulmonary embolism in 4 (5%). No postoperative thromboembolisms occurred in the 17 patients receiving preoperative aspirin or ibuprofen, whereas they did occur in 25% of the remainder (15/60). Thromboembolism after pulmonary resection was more frequent with bronchogenic carcinoma than with metastatic cancer or benign disease (15/59 [25%] versus 0/18 [0%]; p < 0.01), adenocarcinoma compared with other types of carcinoma (11/25 [44%] versus 4/34 [12%]; p < 0.0004), large primary lung cancer (> 3 cm in diameter) compared with smaller lesions (9/19 [47%] versus 6/40 [15%]; p < 0.0001), stage II compared with stage I (7/14 [50%] versus 7/34 [21%]; p < 0.04), and pneumonectomy or lobectomy compared with segmentectomy and wedge resection (14/49 [29%] versus 1/28 [4%]; p < 0.005). Three of 4 patients with thromboembolism detected preoperatively had operation within the previous year. Postoperative pulmonary embolism was fatal in 1 of 4 (25%) and accounted for the one death. These results suggest patients undergoing thoracotomy for lung cancer, especially adenocarcinoma, should be considered for thromboembolic prophylaxis.

Clip migration in stereotactic biopsy

BACKGROUND Needle localization breast biopsy (NLBB) is the standard for removal of breast lesions after vacuum assisted core biopsy (VACB). Disadvantages include a miss rate of 0% to 22%, a positive margin rate of approximately 50%, and vasovagal reactions (approximately 20%). We hypothesized that clip migration after VACB is clinically significant and may contribute to the positive margin rates seen after NLBB. METHODS We performed a retrospective review of postbiopsy films in patients who had undergone VACB with stereotactic clip placement for abnormal mammograms. We measured the distance between the clip and the biopsy site in standard two view mammograms. The location of the biopsy air pocket was confirmed using the prebiopsy calcification site. The Pythagorean Theorem was used to calculate the distance the clip moved within the breast. Pathology reports on NLBB or intraoperative hematoma-directed ultrasound-guided breast biopsy (HUG, which localizes by US the VACB site) were reviewed to assess margin status. RESULTS In all, 165 postbiopsy mammograms on patients who had VACB with clip placement were reviewed. In 93 evaluable cases, the mean distance the clip moved was 13.5 mm +/- 1.6 mm, SEM (95% CI = 10.3 mm to 16.7 mm). Range of migration was 0 to 78.3 mm. The median was 9.5 mm. In 21.5% of patients the clip was more than 20 mm from the targeted site. Migration of the clip did not change with the age of the patient, the size of the breast or location within the breast. In the subgroup of patients with cancer, margin positivity (including those with close margins) after NLBB was 60% versus 0% in the HUG group. CONCLUSIONS Significant clip migration after VACB may contribute to the high positive margin status of standard NLBBs. Surgeons cannot rely on needle localization of the clip alone and must be cognizant of potential clip migration. HUG as an alternative biopsy technique after VACB eliminates operator dependency on clip location and may have superior results in margin status.

Mesoaortic compression of the left renal vein (the so-called nutcracker syndrome): Repair by a new stenting procedure

Compression of the left renal vein (LRV) between the superior mesenteric artery and the aorta has been termed the nutcracker syndrome. Although often asymptomatic, this syndrome may result in varicocele, ovarian vein syndrome, and rarely LRV hypertension, pelviureteral varices, hematuria, and flank pain. Previous surgical approaches have included nephrectomy, variceal ligation, nephropexy, or renocaval reimplantation. We report a new LRV stenting procedure that provided relief for a young woman incapacitated by daily left flank pain and microscopic hematuria. Phlebography of the LRV revealed mesoaortic compression associated with a pressure gradient of 12 mm Hg and preferential outflow down large pelviureteral varices. At operation compression of the LRV was corrected with an external stent of reinforced polytetrafluoroethylene. The patient was asymptomatic and free of hematuria for 9 months after operation and follow-up phlebography documented normal renocaval flow, elimination of the pressure gradient, and reduction of the pelviureteral varices. This represents the first description in the vascular surgical literature of this venous compression syndrome, which has been recognized in previous urologic and radiologic reports reviewed herein. Vascular surgeons should be cognizant of the nutcracker syndrome, and we recommend this new stenting procedure as a more simple and physiologic therapy than previous approaches to this problem.

Percutaneous Transcholecystic Approach to the Rendezvous Procedure when Transhepatic Access Fails

PURPOSE Extrahepatic biliary obstruction can be managed endoscopically or percutaneously. When endoscopic therapy fails, percutaneous drainage with or without endoscopic assistance may be performed. However, transhepatic drainage may itself be unsuccessful. In such patients, a transcholecystic approach combined with endoscopic therapy was used to achieve biliary drainage. MATERIALS AND METHODS After attempts at transhepatic biliary drainage failed, a percutaneous cholecystostomy was performed in four patients, with subsequent cannulation of the common bile duct, endoprosthesis insertion, or papillotomy. RESULTS The success rate was 100%, with no major complication or procedure-related mortality. Slight bleeding from a sphincterotomy was the only minor complication. CONCLUSION When percutaneous transhepatic access to the bile duct fails, the transcholecystic route can be safely used with care to successfully achieve biliary drainage.

Isolated symptomatic midcervical stenosis of the internal carotid artery

All carotid arteriograms performed between January 1, 1986 and December 31, 1991 were reviewed for instances of midcervical carotid stenosis. Sixteen cases were identified. A stenosis related to the hypoglossal nerve was specifically identified in three operative reports in the retrospective review. Pathologic examinations of the specimens confirmed the presence of atherosclerotic plaque or fibrous dysplasia. In another case, relief of intermittent neurologic symptoms (TIAs) was obtained by division of the stylohyoid ligament. Prospective observation of five cases confirmed a stenosis immediately distal to a transverse neurofascial band formed by the hypoglossal nerve, which arose with the vagus nerve in three patients, and a large cervical contribution to the ansa hypoglossi in two. Presumably the lesion was caused by the turbulent flow in the internal carotid artery distal to the band. Isolated stenosis of the midcervical internal carotid artery unrelated to bifurcation disease may be the result of turbulence induced by tethering neural or myofascial bands.

Human Laser Angioplasty: Clinical Applications

Angiographically guided balloon dilatation of atherosclerotic vascular lesions is an established non-surgical technique for treating selected patients with occlusive vascular lesions. Balloon angioplasty involves compressing, stretching, and tearing of the arterial intima with subsequent reshaping and healing of the vessel lumen. The atherosclerotic lesion is mechanically displaced but otherwise remains intact. Totally occluding vascular lesions are not amenable to balloon dilatation unless the catheter can be advanced through the occlusion, a practice with inherent complications.