Hannu Savolainen

Distal Pulse Palpation: Is It Reliable?

The aim of this study was to evaluate the reliability of distal pulse palpation. The dorsalis pedis and the tibialis posterior arteries of 25 patients with suspected lower limb arterial disease were independently palpated by three vascular surgeons and three medical students in the outpatient clinic and by two vascular nurses and one physician in the vascular laboratory. The palpation findings were compared to the ankle/brachial index (ABI). Palpable and unpalpable pulses were best separated with ABI 0.76 as the cutoff point. The degree of misdiagnosis was unacceptably high, with an underdiagnosis of more than 30%. The agreement was highest (kappa 0. 68, good) among the vascular laboratory personnel in the peaceful vascular laboratory and lowest (kappa 0.38, fair) among the vascular surgeons in the busy outpatient clinic. The poor agreement and the high proportion of misdiagnosis obtained in the outpatient clinic argue against the use of pulse palpation as a single diagnostic method. Palpable pulses with low ABIs clearly state the need for more objective measurements whenever ischemia is suspected. Yet, by carefully palpating both pedal arteries under good, nonhurried conditions the reproducibility and accuracy of pulse palpation can be tolerable.

Traumatic Inferior Vena Caval Injuries

Twenty-three cases of inferior vena caval injury (1.4% of all operatively managed abdominal injuries) are reviewed. The caval injury presented as free haemorrhage in 15 cases and as a retroperitoneal haematoma in eight. The site of vena caval injury was at or above the level of the renal veins in 14 cases (61%). Successful lateral suture repair was achieved in 18 cases (78%). The overall mortality rate was 39%. Factors positively associated with survival were stab wound, presentation as retroperitoneal haematoma, infrarenal injury, low Abdominal Trauma Index score and small peroperative blood loss. Concomitant injury to the abdominal aorta, liver or kidney worsened the prognosis. The crucial factor in management of inferior vena caval injuries is rapid and effective control of bleeding, whether from the caval or associated injuries.

Influence of transportation distance on mortality in ruptured abdominal aortic aneurysms

Different opinions exist about the influence of transportation distance to vascular surgical emergency service on outcome for ruptured abdominal aortic aneurysms (RAAAs). Therefore, retrospective study based on the Finnvasc registry and the Finnish Cause of Death registry (Statistics Finland) was carried out. A total of 404 RAAAs were registered in the catchment areas of two university hospitals during a four-year period; 203 of them were operated. The operative mortality rate was 50% based on the Finnvasc registry and 55% based on Statistics Finland. The total hospital mortality rate including operated and nonoperated patients was 69% and the overall case fatality including all deaths for RAAA was 77%. There was no association between transportation distance and results of RAAA treatment.

Left atrial rupture following blunt thoracic injury : case report

A 22-year-old man presented with intermittent tachycardia and left-sided flail chest after an automobile accident. Initially his condition was stable, but 7 hours after the injury cardiac asystole appeared. Cardiopulmonary resuscitation was immediately begun and operation was performed. A rupture of the left atrium was successfully repaired without cardiopulmonary bypass.

Results of cardiovascular surgery in the Marfan syndrome. A retrospective study of 49 patients.

To evaluate the outcome of cardiovascular surgery in the Marfan syndrome, the records of 49 patients (median age 35 years) who underwent 60 operations were reviewed. Primary surgery was elective in 39 patients and emergency in ten. Non-dissecting aneurysm with diameter 4-19 cm was present in 34 cases and distal, isolated aneurysm in four. In eight cases there was type A acute aortic dissection with median diameter 5.0 cm. One patient was operated on for mitral valve insufficiency, one for ventricular septal defect and one (acute) for endocarditis. Composite grafts were used for aortic root reconstruction. Operative complications occurred in 24% of the patients. The 30-day survival was 92%. There were five (10%) late deaths. Survival after a median of 8 years postoperatively was 82%. The early and late results of cardiovascular surgery in the Marfan syndrome thus are concluded to be generally favourable. As late reoperation frequently is needed, however, close monitoring is advocated even after successful primary surgery.

Proximal superior mesenteric arterial and venous injuries

In a review of more than 1000 patients with operatively managed abdominal trauma, eight patients with injuries to the proximal parts of the superior mesenteric artery or vein were identified: three with either a superior mesenteric artery or vein injury and two with combined superior mesenteric vessel injuries. All patients were in shock on arrival, and had associated abdominal injuries. All six patients with solitary superior mesenteric artery or vein injuries underwent lateral suture repair of the injured vessel with good results. The combined injuries of both of the superior mesenteric vessels required more complex types of vascular repairs: an interposition saphenous vein graft for the arterial injury and ligation of the vein in one patient who later died of bowel necrosis, and an end-to-end arterial repair and lateral venorrhaphy in the other who had a viable bowel at a second look operation. The overall mortality rate was 13%. The various management options and guidelines for injuries to the proximal parts of the superior mesenteric vessels are discussed.

Nd:Yag Contact Laser in Partial Nephrectomy: An Experimental Study in Piglets

The Nd: YAG contact laser technique with 12 W power output was used in partial nephrectomies in six piglets. Blood loss, total time and number of ligatures needed for haemostasis were compared in six partial nephrectomies performed with a steel scalpel. Mean blood loss was 53 g with the laser and 108 g with the steel scalpel (p less than 0.04). The mean time needed for haemostasis were 9.5 and 16.2 min respectively (p = 0.2) and the average number of ligatures required 1.5 and 8.8, respectively. The mean temperature rise at 5, 10 and 20 mm distance from the resection line was 5.3, 1.2 and 0.3 degrees C, respectively. The use of laser reduced blood loss and shortened the operation time. Further studies are needed concerning renal function after kidney surgery with a laser.

Laser for Harvesting of the Internal Mammary Artery

In 12 piglets both internal mammary arteries were dissected from the thoracic wall without a surrounding pedicle, using low-current electrocautery for one artery and continuous wave contact Nd:YAG laser (12 W) for the contralateral vessel. Changes in the arterial flow surface were evaluated by scanning electron microscopy immediately after dissection and 2 and 5 days postoperatively. Laser dissection was easier, more accurate and as fast as electrocautery. Moderate to severe degenerative changes and endothelial desquamation were seen in the electrocautery group after dissection, but lesser changes in the laser group. The changes decreased within the next 5 days, but two electrocauterized vessels showed thrombosis at 5 days. Stripping of the internal mammary artery with either method requires great care, and Nd:YAG laser offers a promising alternative to electrocautery in harvesting of that artery as a pedicled graft.

Scandinavia and Northern Europe

Abstract In most Northern European countries, the incidence of trauma is low; and the majority of vascular injuries are iatrogenic, up to 79% in some countries. Vascular surgery is an independent specialty or a subspecialty of general surgery; and the vascular surgeon is the one who is mainly responsible for the treatment of vascular injuries, except for Germany and The Netherlands where trauma surgeons perform the first-line surgery. Endovascular treatment options are available in most countries, but mainly in large academic centers. With increasing fragmentation of surgical training and with the growing potential of endovascular treatment options, major challenges remain in both the organization of emergency surgery care and the training of a new generation of surgeons who are capable of working in this new environment.

Healing of bladder wall after contact and non-contact Nd-YAG laser photocoagulation : experimental study in piglets

The healing process of the bladder wall after contact and non-contact Nd-YAG laser irradiation was studied in 18 piglets. The animals were sacrificed 1 h, and 2, 5 and 14 days after photocoagulation. The lesions were examined histologically by light and scanning electron microscopy. Immunohistochemical stains were prepared for visualization of lactate dehydrogenase. Perforation of the bladder wall was found in 2 cases where a contact probe was used (15 W/2 s). A crater in the bladder wall resulting from tissue ablation was seen in all cases immediately after contact laser irradiation. Photocoagulation using a non-contact laser led to white necrosis in the bladder wall. Minimal tissue ablation was evident at the highest power setting used (35 W/2 s). After 2 days inflammation around the lesion was marked. Inflammation with fibroblasts invading the damaged area was seen 5 days after photocoagulation. Fourteen days after photocoagulation minor scar formation was evident beneath the histologically normal epithelium. It is concluded that lesions caused by contact or non-contact Nd-YAG laser photocoagulation will heal within 2 weeks with minor scar formation.