Km Rai

Management of Vascular Injuries in a Forward Hospital

BACKGROUNDnManagement of vascular injuries poses a challenging problem under warlike conditions. Several authorities recommend limb revascularisation only within first 6-8 hours, as the outcome after delayed revascularisation is poor.nnnMETHODSnA retrospective analysis of 61 consecutive patients with vascular injury in a forward hospital over a 25- month period was carried out.nnnRESULTSnVascular injuries constituted 3.1% of all injuries. The mean injury to treatment delay (lag time) was 11 hours, and 10 patients received treatment after 12 hours. The overall amputation rate was 15%, but only 6.5% for those revascularised within 12 hours and 44% for those undergoing surgery after 12 hours (Chi-square 4.59, p < 0.05). Presence of associated fractures was associated with an adverse outcome (Chi-square 4.24, p < 0.05), as was ligation in comparison to revascularisation (Chi-square 7.86, p < 0.005). Popliteal injuries were associated with a high amputation rate.nnnCONCLUSIONSnFailure to revascularise (ligation of artery), presence of associated fracture, and restoration of circulation beyond 12 hours are associated with a high amputation rate.

SUPRACLAVICULAR FIRST RIB RESECTION FOR TREATMENT OF THORACIC OUTLET SYNDROME

Twelve patients with thoracic syndrome were operated during a 15 month period. Eleven patients had features of neurogenic thoracic outlet syndrome, while one presented with arterial ischemia due to distal embolism. The diagnosis was based on the characteristic history and positive stress tests. Cervical rib was present in 7 patients. Abnormal nerve conduction studies were present in 7 out of 8 cases. Supraclavicular first rib resection was done in all patients in view of the severity of symptoms. If present, the cervical rib was also excised. There was no major operative complication. Eleven out of twelve patients reported relief of symptoms. Thoracic outlet syndrome is not an uncommon disorder and often goes undiagnosed. Resection of first rib via the supraclavicular approach gives good results in majority of the patients who have incapacitating symptoms.

SURGICAL AND ENDOVASCULAR TREATMENT OF AORTIC ANEURYSMS

The surgical management of aortic aneurysms (AA) has undergone a dramatic change in the last decade. Endovascular grafts introduced by a small arteriotomy or percutaneously are increasingly replacing open surgical operations. This minimally invasive procedure of endovascular grafting of aortic aneurysms can be considered a true revolution in the field of vascular surgery. n nThis textbook on conventional surgical and endovascular management of aortic aneurysms, the first in the new millennium, has been published as a companion to the European Vascular Course conducted by the European Society for Vascular Surgery. The contributors to this fairly comprehensive book are renowned vascular and endovascular specialists mainly from Europe; there are some from North America too. The production quality is excellent. n nThe book consists of 32 chapters covering the subject on almost all the aspects from epidemiology and natural history of aortic aneurysms to the surgical risks and quality of life after elective aneurysm repair. The hulk of the chapters (18) and the initial thrust, not surprisingly, have been on endovascular management of aneurysms. This new technology threatens to overtake conventional management of AA, though presently only about 20–50% aneurysms qualify for such treatment. Laparoscopic aortic surgery and video assisted aortic surgery has also been included in the volume to give a comprehensive overview of the subject. n nThe authors and editors arc to be commended for bringing out an excellent book for all personnel involved in the management of AA, especially those involved in its endovascular treatment. (vascular surgeons, interventional radiologists and cardiologists). However, despite some excellent chapters like the one on Preoperative imaging techniques by Jan Blankensteijn, the book gives an impression of being hurriedly compiled. The sequencing of chapters could have been better (eg. Chapter 23 on risk, assessment could have come earlier as the risk assessment is similar in both procedures (open repair or endovascular), and He latter procedure occasionally requires conversion to open repair. Technical aspects of placement of AAA devices, as well as intraprocedure difficulties and their solution (troubleshooting) have not been addressed at all. A volume of this nature could have done with some more diagrams/photographs. Conceptual issues like whether routine suprarenal fixation of AAA (as in Talent and Zenith endografts) is better than the infra renal fixation have not been discussed. “Hybrid procedures” (combined endovascular and open approach) do not find a mention, nor do the percutaneous devices (eg. Perclose) for AAA device insertion. The important issue that several aortic endografts have been withdrawn from the market after fairly extensive use (was the insertion of these “suboptimal” devices ethical in the first place?) has also been ignored. n nIf this critique appears harsh, I can only state that better was expected from an international publication of this stature from Europe. Perhaps it is difficult to do justice to this rapidly evolving and expanding field of endovascular management of AA. The authors have largely, but not completely succeeded in their stated aim of providing, “comprehensive textbook, concentrating on crucial subjects related to the treatment of aortic aneurysms”. n nNotwithstanding its shortcoming the book is strongly recommended for practising vascular surgeons and other specialists actively involved in the conventional (surgical) or endovascular management of aortic aneurysms. It will also be a useful addition as a reference manual to the libraries of Medical Colleges and large hospitals.

ENDOTHELIAL CELL CULTURE AND SEEDING OF PROSTHETIC VASCULAR GRAFTS: AN EXPERIMENTAL STUDY

Current synthetic vascular prostheses do not acquire lining of vascular endothelium in humans or dogs. Endothelial seeding of vascular grafts has been proposed as a means of reducing the thrombogenicity of these grafts. We examined feasibility of cultivating endothelial cells (EC) by tissue culture technique and their subsequent seeding onto small diameter polytetra fluoroethylene (PTFE) grafts. Twenty adult dogs underwent common carotid artery interposition with 4 mm PTFE grafts. Ten dogs received seeded and the remaining ten received unseeded grafts. Grafts were removed at 4 and 12 weeks and their gross/morphological features compared. Cumulative patency rates for seeded grafts were 70% as compared to unseeded ones 30%. Seeded grafts were completely surfaced with a mono-layer of endothelium by 4 weeks. Small graft patency appears to be related to the establishment of an endothelial surface, the development of which is clearly facilitated by seeding with autogenous endothelium.

REVASCULARIZATION OF THE ISCHEMIC UPPER LIMB

Eighteen cases of upper limb ischemia were operated during a 24 month period. Eleven patients presented with features of chronic ischemia, while 7 had acute ischemia with a threatened limb. There were 15 males and 3 females. The average age was 38 years. Associated medical problems were present in 8 patients. Limb perfusion was restored in all patients after direct arterial (bypass) surgery, intra-arterial thrombolysis or percutaneous transluminal angioplasty (PTA). There was no mortality. The limb salvage rate was 100 per cent. Follow-up of upto 24 months reveals a patent bypass in all patients with no recurrence of symptoms. Upper limb ischemia is not uncommon, and can be treated by thrombolysis, angioplasty or bypass surgery. Direct arterial surgery for upper limb revascularization, though technically demanding, is safe and results in relief of symptoms in the vast majority of patients.

Short term results of direct arterial surgery for chronic occlusive peripheral vascular disease

Occlusive peripheral vascular disease (PVD) due to stenosis or occlusion of arteries is not an uncommon problem in our country. The patients are often young and present with intermittent claudication, rest pain, digit ulceration or gangrene. Conservative management is sometimes helpful but direct arterial surgery, where feasible, gives the best results. This is a report of the initial 25 consecutive PVD patients operated at our institution during a ten-month period beginning January 1994. All patients were males, and the average age at operation was 44 years. The indication for surgery was severe intermittent claudication of limb salvage. Standard operative techniques were employed, and either ePTFE or saphenous vein was utilised as the graft material. Three patients had graft occlusion in the immediate postoperative period necessitating reexploration. Follow-up of up to ten months reveals a patent bypass in all but 2 patients. Shortterm patency rate of 92% has been achieved, and amputation was avoided in 6 months.