Roy D. Kohl

Surgical procedures in the management of Takayasu's arteritis

Takayasus arteritis is an inflammatory arteriopathy that often progresses to obliteration of multiple large arteries. Variable results have been reported after medical and surgical management. Twenty female patients with Takayasus arteritis were treated from 1973 to 1989. Eleven (55%) patients had hypertension. Upper or lower extremity ischemia was present in 12 (60%) patients and cerebrovascular insufficiency in seven (35%). Nine patients initially managed with corticosteroids had no improvement in signs or symptoms of arterial insufficiency. Eleven patients had 16 vascular procedures for the following indications: renovascular hypertension (6), extremity ischemia (5), cerebrovascular insufficiency (2), dilation ascending aorta with aortic insufficiency (1), thoracic aortic aneurysm (1), abdominal aortic aneurysm (1). Procedures included aortorenal bypass (5), carotid-subclavian, axillary, or brachial bypass (4), aorto-carotid bypass (2), aneurysm resection (2), supra-celiac aorto-femoral bypass (1), ascending aorta/aortic valve replacement (1), and nephrectomy (1). Clinical improvement occurred in all patients. There were no operative deaths. All are alive at a mean follow-up of 5.75 years (6 months to 16 years). Revision of the initial reconstruction has been required for recurrent renovascular hypertension in one patient and extremity ischemia in another. The other nine patients remain symptomatically improved. Symptomatic Takayasus arteritis frequently requires arterial reconstruction. Symptomatic improvement and excellent long-term graft patency can be expected after arterial reconstruction.

False Aneurysm of the Femoral Artery following Total Hip Surgery

Many common surgical complications have been reported with total hip replacement surgery 2,4,9*10. Much attention has also been devoted to the pulmonary and cardiovascular responses elicited by the monomeric methylmethacrylate in the 1iquid.component of the cement The present case report is that of a mechanical complication perforation of a vessel by the methylmethacrylate polymer. The only other similar mechanical complication we were able to find in the literature is a single case report by Casagrande and Danahy, where methylmethacrylate was found to have extruded through drill holes in the acetabulum, pressing on the sciatic nerve 3. That case and our own illustrate two possible mechanical difficulties that can result from use of the cement.

Direct revascularization for the treatment of forearm and hand ischemia

During an 8-year period, 65 patients underwent operation for ischemia of the arm and hand. Fifty-four patients presented with an acutely ischemic extremity. Twenty-two had cardiac origin emboli, 9 had arterial-arterial emboli, 8 had traumatic occlusion of the brachial artery, and 15 patients developed arterial insufficiency after iatrogenic intervention. Twenty-one of 22 patients with cardiac emboli were successfully treated with embolectomy alone. The majority of patients with arterial-arterial emboli and traumatic or iatrogenic injuries required arterial reconstruction in addition to clot retrieval. After operation, 53 of 54 patients were asymptomatic. Eleven patients underwent operation for chronic ischemia. Seven patients had axillo-brachial saphenous vein grafts, two had carotid-subclavian bypass grafts, and two patients underwent aorto-innominate bypass. All grafts remained patent during follow-up that ranged from 6 months to 8 years. We conclude that operative therapy is very effective in preventing limb loss and functional impairment in patients with acute or chronic upper extremity ischemia.

Bilateral Infrapopliteal Artery Aneurysms

The authors report the case of a 37-year-old man with bilateral posterior tibial artery aneurysms and concomitant collagen vascular disease. The patient initially presented with pain and swelling of the calves. The diagnosis was made by duplex scan and confirmed with arteriography. Diagnostic studies later verified the presence of a lupus-like syndrome. To date, 10 patients with aneurysms of the infrapopliteal arteries have been reported in the literature; four of these have had associated systemic diseases. These reports are reviewed; their clinical manifestations are discussed, and a treatment plan for these uncommon lesions is presented.

Selective use of the intensive care unit after nonaortic arterial surgery

PURPOSE The purpose of this study was to determine whether the institution of a clinical protocol combining 6 hours of recovery room observation and guidelines for intensive care unit (ICU) admission would allow selected patients to be safely transferred directly to a surgical floor after nonaortic arterial reconstruction. METHODS After a clinical pathway was formed, 134 consecutive patients undergoing 154 nonaortic arterial operations were prospectively enrolled in this study. Patients requiring ICU care and the responsible factors were identified. Comparisons of risk factors and demographics were made between those patients who did and did not require ICU care. RESULTS Twelve (7.8%) patients spent a total of 27 days in the ICU (range 1 to 11 days). As per our guidelines four patients were transferred to the ICU for invasive monitoring, and four were sent to the ICU because of refractory hemodynamic instability or arrhythmia in the postanesthetic recovery room. An additional four patients were transferred to the ICU after having been on the surgical floor for 24 to 72 hours because of the following perioperative complications: prolonged chest pain (one), pneumonia (one), heart failure (one), and graft occlusion requiring a urokinase infusion. Patients admitted to the ICU were more likely to have heart disease (p = 0.02) and to have had an operation other than carotid endarterectomy (p = 0.04) than those who were not. The 30-day mortality rate was 1.4%. CONCLUSIONS The implementation of a clinical protocol similar to the one used in this study will allow many patients undergoing nonaortic vascular surgery to avoid the use of the ICU. This approach will conserve hospital and financial resources without adversely affecting patient morbidity and mortality rates.

Does dextran 40 improve the early patency of autogenous infrainguinal bypass grafts

PURPOSE We determined whether the administration of dextran 40 would increase the early (30-day) patency of autogenous infrainguinal bypass grafts. METHODS During a 4-year period, 244 patients undergoing 273 autogenous infrainguinal bypass grafts were prospectively enrolled into and completed this study. Patients were randomized into two groups; one of the groups received a 72-hour infusion of dextran 40 after surgery, and the other did not. Comparisons were made between those patients who did and did not receive dextran 40 with respect to risks factors, demographics, and early graft patency. RESULTS One hundred twenty-six procedures were accompanied by the use of dextran; 147 were not. There was no significant difference between the two groups with respect to patient age, gender, perioperative risk factors, indication for surgery, or location of bypass graft (popliteal vs tibial). Among those patients receiving dextran, there were eight early occlusions (6.4%) and four deaths (3.2%); 89.7% of the patients were alive with patent grafts 30 days after surgery. In the group not receiving dextran, there were 10 early occlusions (6.8%) and 3 deaths (2%); 90.5% of the patients were alive with patent grafts 30 days after surgery. There was no significant difference between the two groups with respect to rate of early occlusion (p = 1.00), death (p = 0.71), or 30-day patency (p = 0.84). CONCLUSIONS The administration of dextran 40 does not increase the early patency of autogenous infrainguinal bypass grafts. Its routine use during these procedures cannot be recommended.