Else Ribbe

Magnetic resonance imaging and MR angiography of endoluminally treated abdominal aortic aneurysms.

OBJECTIVES To evaluate magnetic resonance imaging (MRI) with gadolinium-based contrast medium-enhanced MR angiography (MRA) for the follow-up of endoluminally treated abdominal aortic aneurysms. DESIGN MRI/MRA, angiography and computed tomography (CT) were performed 1 month after endoluminal stent-graft placement. MRI/MRA was repeated at 6 and 12 months and angiography and CT were added to confirm unexpected findings. MATERIALS Fifteen male patients with endoluminally treated abdominal aortic aneurysms. METHODS MRI with MRA, spiral CT with transverse images and angiography were performed. RESULTS MRI/MRA demonstrated changes of stent-graft morphology, aortic neck- and aneurysmal diameter, stent-graft blood flow, stent-graft leakage, blood flow in lumbar arteries, intra-aneurysmal thrombus, periaortic inflammation and vertebral body infarction. For most of these features MRI/MRA provided more information than angiography and/or CT. MRI was the only method demonstrating thrombus reorganisation and vertebral body infarction. CONCLUSIONS MRI with MRA provides the relevant information needed for follow-up of endoluminally treated abdominal aortic aneurysms (AAA). This may be the method of choice because of its use of contrast media with very low nephrotoxicity, lack of ionising radiation and non-invasiveness.

Biological responses differ considerably between endovascular and conventional aortic aneurysm surgery

OBJECTIVES To determine the inflammatory responses in endovascular abdominal aortic aneurysm (AAA) repair and their relation to clinical findings. DESIGN Prospective non-randomised study. SETTING University Hospital, Department of Surgery. PATIENTS AND METHODS Seven patients treated with an endoluminal procedure (AAA-E) and seven patients undergoing conventional surgery (AAA-C) were included. Inflammatory parameters were assessed by measurements of the cytokines interleukin (IL)-1 beta, IL-6, IL-8 and Tumour Necrosis Factor-alpha (TNF-alpha); analyses of complement proteins C1q, C4, C3, C5a and Terminal Complement Complexes (TCC); haematologic parameters and determination of C-reactive protein (CRP). RESULTS In six of seven patients in the AAA-E group blood pressure decreases were recorded during introduction of the device. IL-6 and CRP levels were found to be significantly higher in AAA-C patients compared to the AAA-E group. On the other hand, high TNF-alpha levels were recorded in the AAA-E group. Less consumption of the complement proteins C1q, C4 and C3 was observed in AAA-E compared to AAA-C patients. Increased C5a levels were recorded in the AAA-C group, whereas only slight fluctuations were noticed in the AAA-E group. TCC levels were unchanged in both groups. CONCLUSION Endovascular aortic aneurysm repair induced a significant inflammatory response, mainly involving TNF-alpha and differing from the findings during open AAA repair. These inflammatory responses were probably related to blood pressure decreases during the procedures. On the other hand, conventional repair induced responses related to the more extensive surgical trauma and reperfusion injury.

Surgical treatment versus thrombolysis in acute arterial occlusion: A randomised controlled study

Thrombolytic treatment has been tried in various forms for acute limb ischaemia with varying degrees of success but is also often accompanied by bleeding problems. The present investigation compares the effect of surgical thrombectomy (TE) and thrombolysis (TL) using recombinant tissue plasminogen activator (rt-PA). Twenty patients with a need for intervention owing to ischaemia lasting more than 24 h but less than 14 days were included. Patients randomised to TE were operated under epidural anaesthesia and patients in the TL group received 30 mg rt-PA during a 3 h period through a catheter placed into the thrombus and advanced as lysis was achieved. Thrombectomy resulted in an immediate restitution of blood flow in six out of nine cases, in three cases a bypass procedure was performed, and one of these failed with a resultant amputation. Thrombolysis gave a good primary result in six cases which lasted in four of them. Three had a subsequent percutaneous transluminal angioplasty. Partial lysis was seen in two cases and a further two failed. Five went to surgery with three bypass and two fogarty procedures being necessary. There was no hospital mortality and there were no bleeding complications due to the rt-PA treatment in this series. In 19 out of 20 patients the circulation was re-established. Appropriate handling of acute ischaemic conditions implies the use of both thrombolysis and appropriate surgical procedures, including distal bypass grafts.

Secondary aortoenteric fistulas--an analysis of 42 cases.

Secondary aortoenteric fistulas are seen with an increasing frequency which parallels the expansion of reconstructive vascular surgery. During a 12-year period 42 cases have been collected from the hospitals, which perform most of the vascular surgery in Sweden (0.7% of vascular operations). Twenty-five were seen after operation for aortic aneurysm, 15 for aortoiliac occlusive disease, one after renal artery ligation (as a part of reconstruction for renovascular hypertension) and one after operation for an iliac pseudoaneurysm. The frequency of complications during and after the primary operation was high. The interval between operation and onset of fistula symptoms was significantly shorter if there had been infectious complications, the median interval was 32 months, the longest being 10 years. The most important symptom was gastrointestinal haemorrhage, consisting of several small bleeds often combined with septic complications. A large number of negative investigations usually preceded the final diagnosis which was made at exploratory laparotomy. After surgery for the fistula the frequency of complications and mortality, were very high. Mortality was 58%, the most common cause of death being a blow out of the aortic stump. Of those leaving hospital, several further operations were performed with a high mortality. Recurrence of the fistula occurred in 16 out of 34 patients who survived surgery. At follow-up (12-74 months after fistula closure) seven patients were still alive.

Immune response to collagen impregnated Dacron double velour grafts for aortic and aorto-femoral reconstructions

This study presents 20 patients, randomised to receive either a collagen-treated or an ordinary Dacron graft for aortic reconstructions, and the results of a skin-prick test, blood parameters and ELISA for anti-collagen antibodies as well as NMR pictures during a 6 week follow-up period. Forty per cent (4/11) of those receiving a collagen impregnated graft had a significantly increased titre of antibodies and NMR revealed in two out of 11 patients either a slightly increased amount of fluid or fibrosis around the graft, both collagen impregnated. No differences were found between the graft groups concerning body temperature and leucocyte or platelet counts. The skin-prick test for collagen was negative in all cases.

Two Year Follow-up of Patients Operated on for Thoracic Outlet Syndrome. Effects on Sick-Leave Incidence

This report is based on 175 cases of Thoracic Outlet Syndrome (TOS) which were followed for two years after resection of the first rib. Good or fair results were achieved in 59%. An anomaly restricting the thoracic outlet was significantly more often found in patients with a good outcome after surgery. The results of surgery correlated well to the time for sick-leave. A conservative attitude to surgical treatment of TOS is recommended, due to the difficulty in establishing the diagnosis.

Influence of some plasma proteins on in vitro bacterial adherence to PTFE and Dacron vascular prostheses

The in vitro adherence of Staphylococcus aureus, Staphylococcus epidermidis and Escherichia coli (one strain of each species) to commercially available, microporous polytetrafluoroethylene (PTFE) and woven Dacron vascular grafts before and after coating with human plasma was compared. Standard size segments of the materials were incubated with 35S‐labeled bacteria for 0.5–18 h and, following washes, the radioactivity associated with the segment was measured. The binding of each of the tested species to native Dacron was higher than to PTFE. After coating with human plasma, however, the binding of all three species to PTFE was significantly enhanced, whereas the binding to Dacron was reduced. In addition, the influence of coating with serum albumin (HSA), immunoglobulin G (IgG), fibrinogen (Fg) or fibronection (Fn) rather than whole plasma was tested. We found that coating with HSA reduced the binding of all three species to Dacron and of staphylococci to PTFE. IgG decreased the binding of S. epidermidis and E. coli to Dacron and of S. epidermidis to PTFE. In contrast, Fg enhanced the binding of S. aureus both to Dacron and PTFE, and that of E. coli to PTFE, but decreased the binding of S. epidermidis and E. coli to Dacron. Fn enhanced the binding of S. aureus to Dacron, and of E. coli to PTFE, but decreased the binding of S. aureus to PTFE and of S. epidermidis both to PTFE and Dacron. Thus, both whole plasma and some isolated plasma proteins were found to modulate bacterial adherence to two tested graft materials. From a clinical point of view, bacterial binding to plasma‐coated rather than native materials may more adequately determine the likelihood of in vivo colonization of the various materials. Furthermore, precoating of materials with selected proteins may be of value in the prevention of graft colonization.

Outcome of treatment of ruptured abdominal aortic aneurysms depending on the type of hospital

OBJECTIVE To compare the outcome of patients operated on acutely for ruptured abdominal aortic aneurysms (AAA) or otherwise symptomatic aortic aneurysms in a university hospital and in two county hospitals by the same group of vascular surgeons. DESIGN Retrospective study. SETTING 1 university and 2 county hospitals, Sweden. SUBJECTS 108 patients operated on urgently for AAA, 81 at the university hospital, and 27 at the county hospitals between January 1992 and December 1998. INTERVENTION Repair of the AAA. MAIN OUTCOME MEASURES Morbidity and mortality. RESULTS 21 of the 81 patients having urgent repair of an AAA at the university hospital (26%) had been transferred from the county hospitals. Thirteen patients were not operated on, 7 because of their poor general condition and great age (median 84 years), 3 who refused operation, and 3 in whom the diagnosis was incorrect. During the same time period a further 27 haemodynamically unstable patients were operated on by the same vascular surgeons at the county hospitals. The on-table mortality for patients with ruptured AAA and shock was 5/43 (12%) at the university hospital and 4/27 (15%) at the county hospitals. The corresponding in-hospital rates were 11/43 (26%) and 11/27 (41%). Mortality was significantly higher if the operation was delayed by more than 45 minutes. The incidence of postoperative complications was the same in both hospitals. CONCLUSION If a patient with a ruptured AAA and shock is admitted to the county hospital and operated on by a specialist vascular surgeon the outcome is fully acceptable. The difference seems to be related to the postoperative period. To what extent the delay caused by the surgeons journey to the county hospital has any influence on the outcome is not possible to evaluate.

Perforated peptic duodenal ulcer in a paraesophageal hernia--a case report of a rare surgical emergency.

BackgroundParaesophageal hernias are quite common and sometimes feared due to the risk of incarceration and strangulation of any herniated organ. The hereby reported combination of an incarcerated paraesophageal hernia containing a perforated peptic ulcer is extremely rare.Case presentationAn elderly man with multiple medical conditions was admitted due to severe upper abdominal pain. The patient was found to have a paraesophageal hernia and underwent a laparotomy. In the hernia, a perforated benign peptic duodenal ulcer was found. The duodenal defect was over-sewn, the hernial defect was closed and the former hernial cavity was drained by a right-sided chest tube. The patient was discharged one month after surgery and was found to do well at follow-up one month after discharge.ConclusionThis is the first report of a patient surviving the extremely rare and life-threatening combination of a perforated peptic duodenal ulcer in a paraesophageal hernia.

Bacterial Adherence to Synthetic Vascular Prostheses and Influence of Human Plasma. An In Vitro Study

The in vitro adherence of Staphylococcus aureus, Staphylococcus epidermidis and Escherichia coli to five commercially available prosthetic vascular graft materials was compared. The influence of precoating the segments with human plasma for 2 h was also studied. S35-methionine was used to radiolabel bacteria. The segments were exposed to bacterial suspensions of approximately 10(7) CFU/ml at 37 degrees C for 0.5-18h. Following repeated washing in phosphate buffered saline (PBS), radioactivity associated with the segments was measured. The adherence of the three clinically relevant bacterial species was higher to untreated Dacron than to gelatin or collagen impregnated/coated Dacron or to PTFE. Furthermore, precoating of grafts with human plasma reduced bacterial adherence to woven Dacron, had a little effect on gelatin coated Dacron, but increased the adherence to collagen treated Dacron and, in particular, to PTFE.