Supapong Arworn

Vascular Pythiosis of the Lower Extremity in Northern Thailand: Ten Years' Experience.

Pythiosis is a disease caused by Pythium insidiosum, a fungus-like organism. P. insidiosum is pathogenic in mammals, particularly in horses, dogs, and humans. Human pythiosis can be classified into 4 types: (1) cutaneous/subcutaneous, (2) ocular, (3) vascular, and (4) disseminated pythiosis. Vascular pythiosis is a rare disease but a serious limb- and life-threatening infection. We reviewed 22 cases over a 10-year period in Maharaj Nakorn Chiang Mai/Chiang Mai University Hospital. The survival rate was around 63.6% during our follow-up period. The only effective treatment was complete excision of the infected tissue, which was done mainly by major amputation, such as above-knee amputation. This report raises awareness of this disease, which needs preemptive diagnosis and appropriate treatment.

Mycotic Abdominal Aortic Aneurysm Due to Streptococcus Suis: A Case Report

BACKGROUND Streptococcus suis is a common infection of pigs. Human infection is often related to accidental inoculation through skin injuries during occupational exposure to pigs and pork. The disease may present as meningitis, bacteremia, and less commonly endocarditis, arthritis, or bronchopneumonia. METHODS Case report and review of the literature. RESULTS We report a case of bacteremia and severe sepsis caused by S. suis serotype 2 complicated by septic arthritis in a 56-year-old male with history of a prior contact with unprocessed pork. The causative agent was isolated from blood cultures and aspirated synovial fluid. The patients condition improved after treatment with penicillin, but he was found subsequently to have an abdominal aortic aneurysm, confirmed by computed tomography (CT) scan. The mycotic aneurysm was successfully repaired using an in situ graft reconstruction. Tissue samples analyzed using polymerase chain reaction identified S. suis serotype 2 as the causative organism. After completion of two weeks of parenteral antibiotics, an oral form of ciprofloxacin (0.25 g twice a day) was continued for one month. The patient was discharged from our institution after uncomplicated recovery. Clinical review, a CT scan, and inflammatory markers nine months after surgery revealed no evidence of infection. CONCLUSION This is the first report of mycotic aneurysm caused by S. suis, which may be an etiologic agent of mycotic aneurysms, especially when complicated by bacteremia in adults with a recent history of contact with pigs or unprocessed pork.

Prognostic factors of leg amputation in patients with vascular injury: a systematic review.

Individual studies on the prognostic factors of leg amputation, due to vascular injury, have been small, and they have produced conflicting results. Reliable data are necessary so that surgery can be targeted more effectively. The authors carried out a systematic review from 1990 to 2002 to identify the high risk of patients to amputation. Meta-analysis was carried out. The authors found that patients with preoperative hypotension, popliteal artery injury, and associated bone and nerve injury had a significantly higher risk of leg amputation than those without these risk factors. Also, patients with postoperative infection had a higher chance of amputation than those without infection. This information is essential for an appropriate evaluation and the treatment of such patients.

Unusual Cases of Hypothenar Hammer Syndrome

OBJECTIVE Hypothenar hammer syndrome (HHS) is a rare occupational disease. The risk group of HHS is patient whose dominate hand used as a hammer. Our study report unusually cases in Chiang Mai University Hospital. RESULT 19 year-old basketball player had right ulnar artery aneurysm for two months. After operation, his symptom was relieved and returned to play basketball again. 65 year-old housekeeper had non-dominated hand ulnar artery aneurysm for two years. After operation she still had hand claudication due to poor run-off vessel. CONCLUSION HHS is previously state in risk group. But from our report there was a risk in different occupation.

Case Series of Isolated Primary Persistent Sciatic Vein

Our study aimed to present a short series on the persistent sciatic vein, a rare venous variation, without Klippel–Trenaunay–Weber syndrome and to review the anatomical consideration of deep venous systems. Four cases of lower-type persistent sciatic vein were found. A combination of May–Thurner syndrome and persistent sciatic vein was found in 2 cases. Non-hypoplastic femoral veins, normal and duplicated, were found in 3 cases. This study concluded that in this persistent sciatic vein, the associated non-hypoplastic femoral vein is not uncommon, and care must be taken about this condition during ultrasonographic examination. Unusual causes of chronic venous insufficiency and other venous anomalies should not be overlooked.

A pararenal abdominal aortic aneurysm with iliac arteries stenosis

A 67-year-old Thai woman had a periumbilical pulsatile mass and abdominal pain for 3 months. Ultrasound imaging of the abdomen revealed a 4.8-cm fusiform dilatation of the abdominal aorta just below the superior mesenteric artery. Her medical history was significant for active smoking and hypertension. On systemic review, she had no history of low back pain, claudication, or postprandial pain. The physical examination revealed decreased femoral pulses and abnormal ankle-brachial indices of 0.57 in the right lower limb and 0.54 in the left lower limb. Computed tomography angiography demonstrated an upper abdominal aortic aneurysm, 4.4 cm 5.0 cm in size, just below the celiac axis origin, with involvement of bilateral renal arteries (A). Calcification along the aortic wall with diffuse thick mural thrombus in the aneurysm was seen. The diameter of the patent lumen was w1.5 cm, and maximal thickness of the thrombus was w1.8 cm. Length of the distal abdominal aorta occlusion was w5.2 cm, from the lower part of the aneurysm just below the renal artery origin to 2.4 cm above the aortic bifurcation. Extensive calcification of the occluded aorta, bilateral common iliac arteries, and proximal external iliac arteries was noted (B/Cover and C). A volume-rendered image showed severe stenosis of the common iliac and external iliac arteries, with reconstitution of the bilateral common femoral arteries by bilateral deep circumflex arteries and inferior epigastric arteries via collateral pathway on bilateral abdominal walls that joined with the superior epigastric arteries and internal mammary arteries (D). Surgical repair of the aneurysm and aortoiliac occlusive lesions was offered but was declined by the patient. The patient consented to the publication of this report.

Aorto-enteric Fistula After Endovascular Abdominal Aortic Aneurysm Repair for Behcet's Disease Patient: A Case Report

Introduction A 42 year old male with Behcets disease (BD) had endovascular treatment of a symptomatic infrarenal abdominal aortic aneurysm (AAA). Thirteen months later he developed haematemesis and melaena. Methods Computed tomography (CT) and angiography showed an aorto-enteric fistula with migration and kinking of the stent graft. Explantation of the infected graft and axillobifemoral bypass, aneurysm sac debridement, and jejunal repair with omental interposition was performed on this severely contaminated patient. Discussion There are no reports of an aorto-enteric fistula secondary to endovascular repair in the literature and this case describes the potential consequences of endovascular repair of AAA in BD. The aorto-enteric fistula was associated with persistent inflammatory aortitis, stent graft kinking, and infection. Five cases of secondary aorto-enteric fistulas following open AAA repair in BD patients have been reported including this case resulting from endovascular repair.

Management of the infected aortic endograft

Although the incidence of abdominal and thoracic aortic endograft infection is infrequent, ranging between 0.2% and 5%, stent-graft infection carries significant morbidity and mortality and exemplifies a formidable therapeutic challenge. The treatment goal is to eradicate the infectious process by endograft explantation, regional tissue debridement, and arterial reconstruction by either an extra-anatomic or in situ grafting procedure using autologous vein, cryopreserved allograft, or antibiotic-soaked prosthetic grafts. Successful treatment should maintain normal arterial perfusion to the visceral arteries and lower extremities. Important treatment adjuncts included antibiotic therapy based on cultures, specific bacterial isolates, and coverage of the repair or aortic stump using an omental wrap. Nonoperative treatment in patients with severe comorbidities that preclude endograft explantation may be appropriate in the setting of low-grade biofilm infection. Percutaneous drainage of the perigraft abscess followed by continuous antibacterial irrigation of the cavity can be utilized, but is associated with a high clinical failure rate.

Endovascular Aneurysm Repair in HIV Patients with Ruptured Abdominal Aneurysm and Low CD4

We report two HIV infected patients with ruptured abdominal aneurysm by using endovascular aneurysm repair (EVAR) technique. A 59-year-old Thai man had a ruptured abdominal aortic aneurysm and a 57-year-old man had a ruptured iliac artery aneurysm. Both patients had a CD4 level below 200 μ/L indicating a low immune status at admission. They were treated by EVAR. Neither patient had any complications in 3 months postoperatively. EVAR may have a role in HIV patients with ruptured abdominal aneurysm together with very low immunity.

Acute Deep Vein Thrombosis in Venous Aneurysm following Closure of the Chronic Traumatic Arteriovenous Fistulae of the Lower Extremities

Chronic traumatic arteriovenous fistula (AVF) commonly results from an unrecognized vascular injury. In this report, there were two cases of chronic traumatic AVF of the legs with a long history of stab (case 1) and shotgun wounds (case 2). Both cases presented with varicose veins together with hyperpigmentation around the ankle of the affected leg. Angiograms showed a single large AVF in case 1, whereas, in case 2, there was a single large AVF together with multiple small AVFs. In both cases large venous aneurysm was found next to a large AVF. An open surgical AVF closure for the large AVF was performed in case 1 successfully, but patient developed acute deep vein thrombosis (DVT) in a large venous aneurysm. In the second case, in order to prevent DVT, only closure of the large AVF was performed, which preserved arterial flow into the venous aneurysm. Case 2 did not have acute DVT. This report raised the concern about acute DVTs in venous aneurysms following the closure of chronic traumatic AVF in terms of prevention. Also chronic traumatic AVF is commonly due to misdiagnosis in the initial treatment, so complete and serial physical examinations in penetrating vascular injury patients are of paramount importance.