Intestinal ischemia after abdominal aortic surgery is a highly lethal complication. In order to evaluate the pathogenesis, the diagnostic modalities and the best management, in a retrospective review, 12 patients undergoing postoperative small bowel or colonic ischemic lesions were identified between 1983 and 1995. Preoperative occlusion of IMA was present in nine patients, while a selective angiography of SMA demonstrated occlusive disease of peripheral branches in two asymptomatic diabetic patients. No patent IMA was ligated. When possible, hypogastric circulation was preserved by distal anastomosis into iliac bifurcation (4 cases). Postoperative leukocytosis or elevated LDH values were present. Colonscopy showed a suspected ischemic colitis in two patients and necrotic lesions in three cases. One patient died and diagnosis was made at autopsy. Nine patients were submitted to reoperation and a bowel resection with a proximal stoma was performed in seven of them. In two patients, the aorta or iliac artery below the proximal anastomosis and hypogastric artery suffered acute thrombosis, while prosthetic grafts were patent. A coagulation disorder caused thrombosis of intramural arterioles of the small bowel while peripheral branches of SMA were pulsatile. Eight of the patients submitted to relaparotomy died; non-operative management resulted in a left colon late stricture, while the remaining patient survived without sequelae. Overall mortality rate was 66.6%. Symptoms of this complication are not specific and diagnosis is delayed; consequently surgical repair is often unsuccessful. One patient with small bowel necrosis after elective AAA resection survived, which is extremely rare.

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[Carotid endarterectomy: what postoperative care is needed?].

With the introduction of the diagnosis-related groups system (DRGs), hospital cost containment without compromising quality of care is recommended. Carotid endarterectomy is an effective stroke prevention treatment; the need for routine postoperative intensive care unit (ICU) admission is questionable and is herein evaluated. Between January 1994 and November 1995, 68 patients underwent 79 carotid endarterectomies (CEAs), under general anesthesia, and were postoperatively monitored in a post-anesthesia care unit. 13 patients presented postoperative hypertension and 3 arrhythmia, while 5 patients (7.3%) experienced postoperative complications. Only 8 patients (11.7%) were admitted in ICU for treatment of persistent hypertension (3 cases) with continuous vasoactive drug infusion or because of postoperative complications. One patient (1.4%) died of post-CEA hyperperfusion syndrome. The use of a step down unit for monitoring patients undergoing CEAs is safe and cost-effective and also may identify patients requiring ICU admission.

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PubMedDate not supplied

Aneurysms of the lower limbs: evaluation and management.

In order to evaluate the results of the conservative follow up vs surgical management of infra-inguinal aneurysms, a retrospective review of 23 patients with 28 peripheral aneurysms of the lower limbs was undertaken. Among them, common femoral (5 cases) and popliteal (16 cases) aneurysms were most frequent; superficial femoral (1) and tibial (1) aneurysms were isolated; 5 patients had bilateral aneurysms. The majority of symptomatic aneurysms presented local discomfort (4), acute (4) or chronic (8) ischaemia. Symptoms of nerve (2) or view (1) compression were less common. Duplex or Color-Doppler Scanning, angio-TC and MR confirmed the clinical diagnosis; arteriography demonstrated the number of patent distal vessels. Nine arterial aneurysms were kept under clinical and ultrasonographic observation; three patients were submitted to delayed surgical repair; a major amputation was required and two of these died of cardiac diseases. In the remaining sixteen cases, early elective surgical repair was performed, with resection or ligation of aneurysms. Two cases of acute limb ischaemia were submitted to successful limb-salvage procedures. A primary amputation was necessary in a case with irreversible ischaemia; a lumbar sympathectomy was performed in a patient with a poor run-off. Dacron (5 cases), PTFE (5 cases) or autologous saphenous vein (11 cases) grafts were used. No post-operative complications or limb-loss occurred. Three patients died of myocardial infarction during the follow up period (mean 28 months). Authors' results suggest that early surgical repair of peripheral aneurysms of the lower limbs is the safest and most effective management.

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