Einar Dregelid

SURGICAL TREATMENT OF POPLITEAL ARTERY ANEURYSMS

Objectives: To report the results of surgical treatment of popliteal aneurysms with respect to symptoms and aneurysm size. Design: A retrospective study based on prospectively registered data, in a single vascular unit. Patients and Methods: Forty-nine patients were subjected to 57 operations from May 1974 to June 2000. Patency and limb salvage rates are compared for limbs with and without symptoms of ischaemia, and for small (2 cm or less) and large (> 2 cm) aneurysms. The long-term survival rate was calculated and compared with that of an age and sex-matched population. Results: The overall 5 year graft patency was 60 %. It was 83 % for asymptomatic limbs and 49 % for limbs with ischaemic symptoms. This difference was significant (p < 0,05). The overall 5 year limb salvage rate was 76 %. It was 100 % for asymptomatic and 64 for symptomatic limbs and this difference was significant (p < 0,05). Twenty-one of the aneurysms were 2 cm or less in diameter and 85 % of these caused symptoms of ischemia. The operative mortality was 4 %. The 5-year survival rate was 57 % and significantly lower than that of a demographically matched population. Conclusion: The results of prophylactic operations for popliteal aneurysms on asymptomatic limbs are significantly better than those of operations done on limbs with ischaemic symptoms. The aneurysm size at which to recommend surgery is still not settled.

Treatment of a Hepatic Artery Aneurysm by Endovascular Stent-Grafting

Aneurysms of the visceral arteries are rare. Traditional treatment has been surgical or endovascular with coil embolization. Recently, however, reports on endovascular therapy with stent-grafts have been published. We report the case of a 61-year-old man who was successfully treated with a stent-graft for a symptomatic combined celiac/hepatic artery aneurysm.

Effective Hemostasis in Severe Mesenteric Vein Laceration with Tachosil ® , using a Low- or Non-thrombogenic Patch to Prevent Tachosil ® -induced Thrombosis

Fibrinogen- and thrombin-coated collagen fleece (FTCC) facilitates surgical hemostasis, and is of particular value during resection of parenchymatous organs. Since thrombosis may ensue if the preparation is unintentionally applied intravascularly, it has not been recommended for treating lacerations of large veins, and no previous reports describe its use in vein repair. Our observations in two patients suggest, however, that FTCC might be indicated for hemostasis in vein injury where vascular suture is difficult or not possible, provided a low- or non-thrombogenic patch is interposed to prevent FTCC-induced vein thrombosis. Our two patients had severe lacerations of the proximal superior mesenteric vein (SMV) not amenable to conventional vein repair. Rapid hemostasis was obtained without suturing using Tachosil®, an FTCC preparation, covered with omentum. In the first patient hemostasis was obtained at the expense of vein thrombosis, apparently due to contact between the coagulant-containing side of Tachosil® and the inside of the vein wall. In our second patient we therefore put a small patch of parietal peritoneum on the section of the Tachosil® targeted to cover the vein tear to avoid direct contact between Tachosil® and the vein lumen. Ultrasound examination 3 days postoperatively, and autopsy 11.5 months later showed that the vein was widely patent with no stenosis or thrombus. Our observations in these two patients were that an FTCC-omentum pack alone secured rapid hemostasis in severe SMV laceration, and when a peritoneal patch was interposed between FTCC and a lacerated SMV, FTCC-induced vein thrombosis did not occur.

Temporary extracorporeal axillo-iliac vascular prosthesis shunt in open repair of a pararenal aortic aneurysm

INTRODUCTION When a long aortic clamp time is expected or when upper body to lower body collateral arteries are sparse, temporary lower body perfusion may be needed to reduce ischemic injury during supraceliac clamping in open repair of pararenal aortic aneurysms. The use of conventional extracorporeal perfusion techniques carry extra risks and is not in the armamentarium of most vascular surgeons. An axillo-femoral or -iliac shunt using a vascular prosthesis does not require the same degree of anticoagulation and causes less activation of blood components. PRESENTATION OF CASE A patient, who had extensive vascular stenotic disease and large bowel ischemia, was operated on for a pararenal aortic aneurysm while the lower body was perfused via a temporary extracorporeal vascular prosthesis axillo-iliac shunt. Copious backbleeding encountered while suturing the proximal anastomosis testified to the efficacy of the temporary shunt. A left hemicolectomy had to be performed for gangrene of the sigmoid colon and he needed 2 days of respiratory support; otherwise the postoperative course was uneventful. DISCUSSION In our case more ischemic injury than that observed might have been expected without the temporary bypass but significant backbleeding may have negated some of the beneficial effect of the shunt. CONCLUSION A temporary axillo-femoral or -iliac shunt prevents lower limb ischemia and provides an ample amount of collateral blood flow to the torso. It does not need to be buried subcutaneously as previously described. Occlusive balloons should be used where possible to prevent backbleeding and to further increase available collateral blood supply.

Temporary extracorporeal brachio-femoral vascular prosthesis shunt for ischemia prevention in an operation for abdominal aortic and iliac aneurysms in a patient with Marfan's syndrome.

In open vascular repair, when prolonged infrarenal aortic clamping can be expected, and collateral perfusion is reduced, the use of a temporary shunt may reduce the risk of ischemic complications. In a patient with Marfans syndrome and aortic dissection who had developed infrarenal aneurysms, segmental arteries had been occluded by prior aortic surgery and collateral arteries in the anterior torso could have been damaged by previous pectus excavatum, muscle flap, sternotomy, and ventral hernia operations. The axillary artery was dilated. For the prevention of ischemia during open repair with a bifurcated graft, a temporary extracorporeal brachio-femoral vascular prosthesis shunt was constructed. Ischemia was not observed. The use of a temporary extracorporeal brachio-femoral shunt with a vascular prosthesis is a feasible method for ischemia prevention.

Novel Visceral-Anastomosis-First Approach in Open Repair of a Ruptured Type 2 Thoracoabdominal Aortic Aneurysm: Causes behind a Mortal Outcome

Case reports to analyze causes and possible prevention of complications in a new setting are important. We present an open repair of a ruptured type 2 thoracoabdominal aortic aneurysm in a 78-year-old man. Lower-body perfusion through a temporary extracorporeal axillobifemoral arterial prosthesis shunt was combined with the use of a branch to the permanent aortic prosthesis to enable rapid visceral revascularization using a visceral-anastomosis-first approach. The patient died due to transfusion-induced capillary leak syndrome and left colon necrosis; the latter was probably caused by a combination of back-bleeding from lumbar arteries causing a steal effect, an accidental shunt obstruction, and hemodynamic instability towards the end of the operation. The visceral-anastomosis-first approach did not contribute to the complications. This approach reduces the time when visceral organs are perfused only via collateral arteries to the time needed for suturing the visceral anastomoses. This may be important when collateral perfusion is marginal.

Treatment of major vein injury with the hemostatic fleece TachoSil by interposing a peritoneal patch to avoid vein thrombosis: A feasibility study in pigs.

Background: Vein lacerations in awkward locations are difficult to repair and carry high mortality. The hemostatic fleece, TachoSil, is effective in preventing intraoperative bleeding in different settings, but has not been recommended for use in large vein injury. TachoSil with a peritoneal patch interposed to avoid vein thrombosis has been reported as a method to obtain hemostasis in vein laceration, but further studies of this method are needed. Materials and Methods: A 1.5 × 1 cm defect was created in the vena cava in five pigs. A 26 × 32 mm peritoneal patch was applied on the coagulant side of a 48 × 48 mm TachoSil sheet, and used to cover the defect. Light compression with a wet sponge was applied for 3 min. No vascular suturing was performed. Results: Successful hemostasis was obtained in four out of the five pigs although the minimum TachoSil gluing zone surrounding the peritoneal patch was only 0–2 mm. The fifth pig died of hemorrhage 30 min after surgery due to a 4-mm stretch with no TachoSil gluing zone outside the peritoneal patch. At six days postoperatively the peritoneal patch was well integrated into the vein wall. After 28 days, the peritoneal patch was almost indiscernible from surrounding vein endothelium. Conclusions: Vein wall defects can be repaired using TachoSil with a peritoneal patch interposed to prevent contact between the thrombogenic TachoSil sheet and the vein lumen. An adequate TachoSil gluing zone all around the patch is essential.

Atheroembolization and potential air embolization during aortic declamping in open repair of a pararenal aortic aneurysm: A case report

Highlights • A case of microembolization in open repair of a pararenal aneurysm is presented.• Only a few out of hundreds of small arteries contained cholesterol emboli.• There was a possibility of remaining air in the aorta/graft at aortic de-clamping.• Air could have been whipped into pulsating blood causing air microembolization.• Air microembolization in open repair of pararenal aneurysms needs to be studied.

Letter by Dregelid Regarding Article, “Intra-Arterial Administration of Bone Marrow Mononuclear Cells in Patients With Critical Limb Ischemia: A Randomized-Start, Placebo-Controlled Pilot Trial (PROVASA)”

To the Editor: During the randomized start phase of the study by Walter et al,1 there was 1 death and 3 major amputations among the 19 patients who got cell injections and 1 major amputation among the 21 patients in the placebo group. The 3-month combined mortality and major amputation rate for the 3 cell injection groups was 10 of 51 versus 1 of 21 in the placebo group. The differences would have been significant if the same rates had been observed in only twice as many patients. Because previous intracoronary cell injection studies had not shown consistently positive effects,2 there was …

Letter by Dregelid Regarding Article, “Autologous Bone-Marrow Mononuclear Cell Implantation Reduces Long-Term Major Amputation Risk in Patients With Critical Limb Ischemia: A Comparison of Atherosclerotic Peripheral Arterial Disease and Buerger Disease”

To the Editor: A main finding in the study by Idei et al1 was that patients who underwent bone marrow mononuclear cell (BM-MNC) implantation had a highly significantly higher major amputation-free survival rate than patients who did not undergo BM-MNC implantation. A major amputation is not a spontaneous event such as stroke or myocardial infarction. Before reaching a decision concerning amputation, there is interaction between the patient and a surgeon. A surgeon nonblinded to type of treatment may have been more prone to recommend amputation in control patients …