J.V. Robbs

Additional renal arteries : incidence and morphometry

Advances in surgical and uro-radiological techniques dictate a re-appraisal and definition of renal arterial variations. This retrospective study aimed at establishing the incidence of additional renal arteries. Two subsets were analysed viz. a) Clinical series-130 renal angiograms performed on renal transplant donors, 32 cadaver kidneys used in renal transplantation b) Cadaveric series - 74 en-bloc morphologically normal kidney pairs. The sex and race distribution was males 140, females 96 African 84, Indian 91, White 43 and “Coloured” 18, respectively. Incidence of first and second additional arteries were respectively, 23.2% (R 18.6% L 27.6%) and 4.5% (R 4.7% L 4.4%). Additional arteries occurred more frequently on the left (L 32.0% R 23.3%). The incidence bilaterally was 10.2% (first additional arteries, only). The sex and race incidence (first and second additional) was males, 28.0%, 5.1% females, 16.4%, 3.8% and African 31.1%, 5.4% Indian 13.5%, 4.5% White 30.9%, 4.4% and “Coloured” 18.5%, 0% respectively. Significant differences in the incidence of first additional arteries were noted between sex and race. The morphometry of additional renal arteries were lengths (cm) of first and second additional renal arteries 4.5 and 3.8 (right), 4.9 and 3.7 (left) diameters 0.4 and 0.3 (right), 0.3 and 0.3 (left). Detailed morphometry of sex and race were also recorded. No statistically significant differences were noted. Our results of the incidence of additional renal arteries of 27.7% compared favourably to that reported in the literature (weighted mean 28.1%). The study is unique in recording detailed morphometry of these vessels. Careful techniques in the identification of this anatomical variation is important since it impacts on renal transplantation surgery, vascular operations for renal artery stenosis, reno-vascular hypertension, Takayasu’s disease, renal trauma and uro-radiological procedures.

Left renal vein variations

The highly complex embryological development of the left renal vein compared to its right counterpart results in greater variations which are clinically significant. The study aimed to identify these variations and to document its incidence. Cadaveric study: 153 kidney pairs were harvested en bloc, dissected, 100 resin casts prepared and 53 plastinated; renal venography performed on further 58 adults and 20 foetal cadavers. Clinical study: (retrospective analysis): a) radiological study, 104 renal venograms; b) live related renal transplantation, 148 donor left kidneys; c) abdominal aortic aneurysm surgery, 525 patients. Total sample size: 1008. Renal collars observed in 0.3%; retro-aortic vein 0.5%; additional veins 0.4%; posterior primary tributary 23.2%, (16.7% Type IB; 6.5% Type IIB, cadaveric series, only). Our results differ significantly in incidence to that reported in the literature: renal collar 0.2-30%; retro-aortic vein 0.8-7.1%; additional renal vein 0.8-6%. Variations are clinically silent and remain unnoticed until discovered during venography, operation or autopsy. To a transplant surgeon, morphology acquires special significance, since variations influence technical feasibility of operation. Prior knowledge of circum-aortic vein is important when blood samples from suprarenal or renal veins are collected. Collar may provide developed collateral pathway immediately after surgery if renal interruption planned without awareness of its presence. Variations restrict availability of vein for mobilisation procedures. In aortic aneurysm repair, retro-aortic vein is important. During retroperitoneal surgery, the surgeon may visualise a pre-aortic vein but be unaware of an additional retroaortic component or a posterior primary tributary, and may avulse it while mobilising the kidney or clamping the aorta.

Arterial aneurysms in patients infected with human immunodeficiency virus: A distinct clinicopathology entity?

Arterial aneurysms have only recently been associated with the human immunodeficiency virus (HIV). The clinical and pathological features of 10 HIV-positive patients with arterial aneurysms were retrospectively evaluated. These aneurysms were unusual in that they affected young black patients, occurred in atypical sites, and tended toward multiplicity. Surgery was performed in eight patients. Acute and chronic inflammatory changes were revealed by means of histologic examination of the aneurysm walls, with occlusion of the vasa vasora by inflammatory infiltrate or edema being a prominent feature. Culture of the aneurysm wall or thrombus yielded positive results in two patients. The association between HIV and aneurysms may be coincidental, caused by direct viral action or by bacterial infection resulting from immunosuppression. Implications for therapy are discussed, and the need for further study is highlighted.

Arterial reconstruction for non-specific arteritis (Takayasu's disease): Medium to long term results

There is little information on reconstructive arterial surgery for Takayasu Arteritis, and the approach is generally negative in this regard. Common causes of death are stroke, aneurysm rupture and the complications of renovascular hypertension and renal failure. The present study aims to examine the results of arterial reconstruction in the medium and long term in patients with histologically proven Takayasus disease. In the last 11 years 134 patients have been referred to the vascular service of whom 81 (60%) were suitable for operation. Forty-nine were women; age range 3-45 years (average 29.5 years). In 28 the disease was confined to the aortic arch (Type 1); 41 had descending aortic involvement (Type II); six had a combination of arch and aortic disease (Type 111) and two associated cardiac lesions (Type IV). Four had isolated peripheral lesions (Type V). Seventy percent of these lesions were aneurysmal. Of the 28 type I patients, two had aortic arch reconstruction, seven segmental replacement. Of the 49 with type II, III and IV disease 26 had thoraco-abdominal aortic replacement using a bypass technique. The remainder had infrarenal aortic replacement and bypass procedures. Type V (four patients) had interposition grafts. Overall operative mortality in the Type I patients was 3.6% (stroke) and in the type II-IV 4%. All of the latter followed operation for aneurysm rupture and there were no elective deaths. Three months to 11 years after operation four patients (5%) developed fatal progression of the disease and seven (8.9) non-fatal disease progression of whom three required surgical intervention.(ABSTRACT TRUNCATED AT 250 WORDS)

Nonpenetrating subclavian artery trauma

Nonpenetrating injury to the subclavian vessels is uncommon. During a 6-year period we have treated 167 patients with injuries to the subclavian and superior mediastinal arteries. Fifteen of these injuries (9%) occurred after blunt trauma. In 10 patients the proximal segment (first and second parts) of the artery was involved. No patient had an isolated injury; the most frequent associated injuries were rib fractures (n = 11), with the first rib being involved in four of these. Total brachial plexus disruption was found in nine patients. All patients with distal artery involvement had a clavicular fracture. All had an absent radial pulse and eight had critical ischemia of the hand. Four patients were treated nonoperatively and the remainder were treated along standard lines. Brachial plexus reconstruction was not feasible in any patient. Within 2 weeks of operation, one patient died as a result of head injuries and one required amputation because of sepsis. During a 12-month period, five regained full function, one additional patient requested above-elbow amputation after 6 months, and seven had a flail anesthetic limb. Twelve of these patients were involved in automobile accidents, eight of whom were wearing lap-shoulder harness seat belts with a loose-fitting shoulder strap component that created a characteristic abrasion pattern on the torso and chest. We conclude that the torsionshearing motion allowed by this situation contributed significantly to the pattern of injury and a plea is made for correctly fitted restraining devices.

Shark attack: review of 86 consecutive cases.

BACKGROUND On average there are approximately 50 confirmed shark attacks worldwide annually. Despite their rarity, such incidents often generate much public and media attention. METHODS The injuries of 86 consecutive victims of shark attack were reviewed from 1980 to 1999. Clinical data retrieved from the South African Shark Attack Files, maintained by the Natal Sharks Board, were retrospectively analyzed to determine the nature, treatment, and outcome of injuries. RESULTS The majority of victims (n = 68 [81%]) had relatively minor injuries that required simple primary suture. Those patients (n = 16 [19%]) with more extensive limb lacerations longer than 20 cm or with soft-tissue loss of more than one myofascial compartment were associated with higher morbidity and limb loss. In 8 of the 10 fatalities, death occurred as a result of exsanguinating hemorrhage from a limb vascular injury. CONCLUSION Victims of shark attack usually sustain only minor injuries. In more serious cases, particularly if associated with a major vascular injury, hemorrhage control and early resuscitation are of utmost importance during the initial management if these patients are to survive.

Operative treatment of nonspecific aortoarteritis (Takayasu's arteritis)

Operative treatment of nonspecific aortoarteritis remains controversial and little information is available on the results of reconstruction of extracranial cerebral vasculature in this disease. Our experience with 25 patients with histologically proven symptomatic disease treated during a 4-year period is presented. The aortic arch and its branches were involved in 12 patients and 13 had disease affecting the descending aorta and its tributaries. Patients with cerebrovascular disease had aneurysms, minor stroke, or intermittent neurologic dysfunction. Descending aortic involvement resulted either in symptomatic or ruptured aneurysm and renovascular hypertension. Operative treatment of cerebrovascular disease comprised aortic arch (three patients), carotid (three patients), or subclavian artery reconstruction (six patients). Descending aortic reconstruction comprised thoracoabdominal (four patients) or infrarenal (five patients) aneurysmorrhaphy, abdominal aortic replacement with bilateral renal artery reconstruction (two patients), and nephrectomy (two patients). One early postoperative death occurred because of stroke. Twenty-four survivors have been observed between 3 and 42 months. No deaths or further neurologic episodes have occurred during this period and three of five hypertensive patients were cured. We conclude that symptomatic aortoarteritis, including cerebrovascular disease, may be treated by standard operative techniques with rewarding results.

Arterial complications of the thoracic outlet syndrome

OBJECTIVES Arterial complications due to compression of the thoracic outlet are uncommon. The objective of this study was to review our fairly extensive experience with this problem with particular reference to its management. METHODS Patients entered into the Vascular Clinic database were reviewed over an 11 year period. Twenty six records were found. In 24 patients the vasculopathy was caused by a cervical rib (complete in 15) and in two by an anomaly of the first rib. In all patients the basic arteriopathy was a fibrous structure with a post-stenotic aneurysm in 13. Seventeen presented with a fixed pulse deficit; 13 had a palpable aneurysm and 12 had distal embolisation. RESULTS Two patients refused operation. In 22 with cervical rib, the rib was removed via a supraclavicular incision, an anterior scalenectomy was performed and the arterial pathology repaired on its merit, usually by vein graft replacement or bypass. In two with first rib anomalies these were resected by the transaxillary route. Twenty three patients have been followed for between 3 months and 10 years; 20 are cured and three have residual claudication. CONCLUSIONS Our results show that simple excision of the cervical rib via the supraclavicular route together with vascular reconstruction is adequate. This is in disagreement with the view of those who advocate routine excision of the first rib in addition to cervical rib excision.

Carotid artery aneurysms in patients with human immunodeficiency virus.

OBJECTIVES Carotid artery aneurysms, although rare, are increasing in frequency due to their association with human immunodeficiency virus (HIV) disease. Our institution serves a population with a high HIV prevalence and we wished to document our growing experience with this aneurysmal pathology in a setting of an ever-increasing burden of HIV disease. METHODS Data on all patients managed at Inkosi Albert Luthuli Central Hospital in Durban, South Africa, from July 2003 to December 2009 with HIV carotid aneurysms were extracted from a prospective vascular database and their case records were examined. Twenty-two patients were identified of whom 21 had preoperative imaging and underwent some form of intervention. RESULTS The initial presentation in 19 of the 22 patients was a progressively enlarging neck mass and pain. Ten patients presented with neurology with only 1 patient presenting with a hemiplegia and 1 patient with a monoplegia. Sixteen patients had an open operative repair and 5 patients had an endovascular repair performed as the initial procedure. Of the open procedure, 8 patients had an interposition graft used and 8 had ligation of the common carotid artery (CCA), external carotid artery (ECA), and/or internal carotid artery (ICA). Eighteen patients had no immediate postoperative neurological complications. The worst outcomes were from patients who underwent an endovascular procedure. These included one death, two thrombosed stents, and one endoleak. Histology showed active tuberculosis (TB) in 6 patients who were not known to have TB preoperatively. The overall mortality was 3 of 22 patients. CONCLUSION We have noted aneurysms of the carotid artery to occur in patients who are infected with HIV and it seems to be that the incidence of such aneurysms is more common than documented. Open surgical intervention either in the form of an interposition graft or ligation seems to be the more effective treatment option as compared to endovascular stenting. Stenting should be reserved for those patients unfit for open surgery.

A comparison of laser doppler fluxmetry and transcutaneous oxygen pressure measurement in the dysvascular patient requiring amputation

OBJECTIVE To determine the predictive power of laser Doppler fluxmetry (LDF), both heated and unheated, as a preoperative investigation of wound healing potential in dysvascular patients requiring amputation, by comparison with transcutaneous oxygen pressure measurement (TcpO2) and the limb to chest TcpO2 index. METHODS Thirty-five non-diabetic patients with peripheral vascular disease were investigated before amputation. Heated and unheated LDF and heated TcpO2 measurements were taken on the chest wall and at the routine above-knee, below-knee and mid-foot amputation levels. Wound healing potential was evaluated against a TcpO2 index value of 0.55 and on clinical outcome. RESULTS A heated LDF value of 4.9 arbitrary units (au) was shown by receiver-operator characteristic curve to have the best predictive power, with an overall accuracy for preoperative prediction of wound healing of 91.4%, and a predictive value for wound failure of 89%. Based on the heated LDF of 4.9 au, review of 26 amputations performed shows the overall accuracy for preoperative prediction of wound healing of 92.3%, a predictive value for wound healing of 100%, and a predictive value for wound failure of 62.5%. CONCLUSION A heated LDF value of 4.9 au appears to be a useful predictor of the potential of an amputation site to heal.