Kishore Sieunarine

Comparison of Transperitoneal and Retroperitoneal Approaches for Infrarenal Aortic Surgery: Early and Late Results

The retroperitoneal approach to the infrarenal aorta was purported to have a shorter recovery and reduced degree of surgical stress than the transperitoneal approach. Hence, this study aimed to determine any advantages of one approach over the other. One hundred patients undergoing infrarenal aortic surgery between 1989 and 1992 were randomized to the transperitoneal or retroperitoneal approach; 64 operations were for aneurysms (32 transperitoneal, 32 retroperitoneal) and 36 for occlusive disease (18 transperitoneal, 18 retroperitoneal). Parameters monitored were operating time, cross-clamp time, blood loss, fluid requirement in first 24 h, analgesia requirements, gastrointestinal function, morbidity, mortality and length of stay in intensive care and hospital. A minimum 3-year follow-up was obtained to assess mortality and wound problems. Inter-group demographic data were comparable. There was no significant difference between the two approaches for: operating time 190 versus 202 min, P = 0.26); cross-clamp time (72 versus 81 min, P = 0.93); blood loss (1095 versus 1072 ml, P = 0.56); 24-hour fluid requirements (6900 versus 7000 ml, P = 0.45); analgesia requirements (60 versus 55 mg, P = 0.37), gastrointestinal function, morbidity (P = 0.75), mortality, and length of stay in intensive care (2 versus 2 days, P = 0.80) and hospital (10.5 versus 10 days, P = 0.76). In the long term there were significantly more wound problems (bulging, hernias and wound pain) in the retroperitoneal group. Long-term mortality was similar in both groups.

Deep venous valve reconstruction for non-healing leg ulcers: techniques and results.

Background:  The purpose of the present paper was to report clinical and imaging results of a 5 year experience of deep venous valve surgery with evaluation of end‐points at 2 year follow up for the management of non‐healing venous leg ulcers in 137 patients.

Stenting for carotid artery stenosis: Fractures, proposed etiology and the need for surveillance

PURPOSE Carotid artery stenting is a relatively new intervention for the treatment of carotid artery stenosis, and the long-term outcomes and complications are therefore yet to be determined. In one surgeons practice, it was found that a stent fracture was the etiological factor for recurrent stenosis. A retrospective study was therefore performed with the hypothesis that carotid stent fractures are common. The aims were to determine prevalence of fractures in this surgeons series, risk factors, and most importantly, clinical relevance. METHODS Patients from one surgeons private practice who had carotid stenosis deemed suitable for intervention (>80% asymptomatic, >70% symptomatic, 50% to 70% if an ulcerated lesion) and had suitable aortic and carotid morphology for carotid stenting between March 2004 and December 2006 were included. To enhance the quality of the measurement, two vascular surgeons and one radiologist examined the films independently to determine if there was a fracture present. Given that this was a retrospective study, there was no preconceived sample size determined. RESULTS Fracture prevalence was found to be 29.2% or 14 out of 48 stents. Restenosis occurred in 21% of those stents with a detected fracture, after an average follow-up of 15 months. Several anetiological factors are proposed, with a finding in this series, of a strong and significant association between the presence of calcified vessels and the presence of fractures (odds ratio 7.7; standard error 5.6; 95% confidence interval 1.9-32.0, P =.003). CONCLUSIONS Although this is a small study, it demonstrates that carotid stent fractures do exist, and importantly, not all of them are benign. Therefore, the authors recommend regular surveillance with plain radiography in addition to duplex ultrasonography to enable early detection of fracturing. Following detection, institution of increased surveillance frequency and/or any appropriate intervention can be implemented, to aid in the prevention of complications resulting from restenosis should it become apparent.

The Perth HLB Bifurcated Endoluminal Graft: A Review of the Experience and Intermediate Results

Endoluminal grafting for abdominal aortic aneurysm based upon Dacron-coated Z stents was commenced in March 1993. A modular system for treatment of infrarenal aorto-iliac aneurysmal disease was developed in 1994. The experimental model, method of delivery, graft construction and initial results were reported. Since 1994, 108 bifurcated HLB (Perth) endografts for infrarenal aorto-iliac aneurysmal disease have been implemented. Initial technical success in deployment and exclusion of the aneurysm was achieved in 94 (87%) cases. Secondary endovascular procedures were performed in six cases and were successful in excluding the aneurysm. Ninety patients are alive currently. Twelve have died of co-morbid conditions. Six have died of aneurysmal disease, either from rupture or the result of treatment attempts. Fifteen early endoleaks (within 30 days) have been detected with three persisting. Four have sealed without further intervention, six after the secondary procedure and two patients have died. Conversion to open aneurysmal repair has been performed in five cases: three early and two late. Two of the early group but none of the late intervention group died. No graft infections have been detected to date. With increasing experience criteria for patient selection for endoluminal grafting and the type of graft to be inserted, have been developed. These criteria, lessons learnt and technical points of importance are discussed.

Successful embolization of persistent endoleak from a patent inferior mesenteric artery.

PURPOSE To report the successful endovascular occlusion of a persistent endoleak owing to collateral perfusion in a 1-year-old bifurcated aortic endograft. METHODS AND RESULTS An 81-year-old man underwent endovascular repair of a 5.5-cm abdominal aortic aneurysm (AAA) with a bifurcated stent-graft in 1995; collateral perfusion of the excluded aneurysm by retrograde filling of the patent inferior mesenteric artery (IMA) was noted postoperatively. At his 1-year follow-up, the mid-sac endoleak persisted on contrast-enhanced computed tomography. Using the superior mesenteric artery for access, the stump of the IMA was successfully embolized with glue. CONCLUSIONS This case, which highlights the importance of documenting a patent IMA prior to AAA endografting, illustrates one option for the management of persistent collateral perfusion of endovascularly excluded aneurysms.

Hybrid Open-Endoluminal Technique for Repair of Thoracoabdominal Aneurysm Involving the Celiac Axis

PURPOSE To describe a technique combining endoluminal and open approaches for the repair of thoracoabdominal aneurysms involving the celiac axis. CASE REPORT Two patients with type I thoracoabdominal aneurysm and suboptimal cardiac reserve underwent transluminal stent-graft implantation. To achieve satisfactory distal seal, the caudal end of the endograft was circumscribed with a Dacron band that was sutured to the aorta and endograft through a midline incision. The patent celiac artery in both patients was ligated to stop retrograde filling of the aneurysm sac. The patients developed no problems perioperatively, and exclusion of the aneurysms was confirmed by follow-up imaging. Three years after endografting, both patients had excluded aneurysms without evidence of endoleak or device migration. CONCLUSIONS This combined approach is another treatment option for thoracic aneurysms that have an anatomically suitable proximal attachment zone with a compromised distal neck.

An epidemiological view of vascular trauma in Western Australia: A 5‐year study

Background: Although Australia encounters vascular injury less frequently than countries such as the USA, the predominance of blunt trauma with associated complex injuries continues to pose problems for clinicians. The present paper reviews Royal Perth Hospital’s experience of vascular trauma epidemiology.

Popliteal artery injury: Royal Perth experience and literature review

Background:  Popliteal artery injury is uncommon but poses a significant challenge in Australian trauma care. Blunt trauma and knee dislocations appear to be associated with higher amputation rates. The aim of the present study was to review the authors’ experience with this condition and discuss the best approach to investigation and management.

Cutaneous mucormycosis and motor vehicle accidents: Findings from an Australian case series

Cutaneous disease is the third most frequent manifestation of mucormycosis. The clinical manifestations of and subsequent mortality due to cutaneous mucormycosis are dependent on the mode of acquisition and the host immune status. Here, we describe the epidemiology, clinical presentation, microbiology, and outcomes of 16 cutaneous mucormycosis infections managed in an Australian tertiary hospital over a 15-year period. The proportion with localized (56%), deep (38%), and disseminated (6%) cutaneous disease as well as the overall mortality (25%) were consistent with findings reported in the published literature. Two novel forms of hospital-acquired infection were reported following a sacral pressure sore and insertion of a foreign body during a bone graft procedure. The majority of patients were immunocompetent (75%) and/or suffered trauma (56%) with associated environmental contamination. A novel finding was that motor vehicle accidents (MVAs) accounted for 78% of all trauma-related cases, suggesting MVAs should receive greater recognition as a potential precipitant of cutaneous mucormycosis. Aggressive decontamination and debridement of devitalized tissue following trauma is therefore likely to play an important role in the prevention of this rare but potentially devastating infection.

Spontaneous common iliac artery dissection after exercise.

Purpose: To review the clinical features and management of spontaneous iliac dissections. Case Report: A healthy 60-year-old competitive cyclist presented with acute onset of short-distance claudication following vigorous exercise. Angiography showed a dissection flap extending from the right common iliac artery to the external iliac artery. An uncovered stent was placed across the proximal entry site but did not obliterate the false lumen; open surgical intervention was required. Conclusions: Spontaneous dissection of the iliac artery is a rare but important condition to suspect in high performance athletes complaining of leg pain following exercise.