Biomedical subjects
Publications and source records attributed to L Golcman.
A case of brachial artery pseudoaneurysm in a premature infant is reported. The lesion was surgically resected, and arterial continuity restored by end to end anastomosis. The postoperative period and follow up were uneventful.
BACKGROUND: Both diagnostic and therapeutic options in the management of iatrogenic false aneurysms have changed dramatically in the last decade, with surgery being required only rarely. OBJECTIVE: To describe our experience, techniques and results in treating pseudoaneurysms at a large medical center with frequent arterial interventions. We emphasize upper limb lesions. MATERIALS AND METHODS: We reviewed the data of all consecutive patients diagnosed by color-coded duplex Doppler between August 1992 and July 1998 as having upper limb and lower limb pseudoaneurysms (mainly post-catheterization). We accumulated 107 false aneurysms (mainly post-catheterization lesions): 5 were upper limb lesions and 102 were groin aneurysms. RESULTS: In the lower limb cases 94 of the 102 lesions were not operated upon (92.1%). Seventy lower limb cases were treated non-operatively by ultrasound-guided compression obliteration with a 95.7% success rate (67 cases). Two cases were treated by percutaneous thrombin injection (2%) and 23 by observation only (22.5%). Altogether 12 patients underwent surgery (11.2%): 4 upper extremity and 8 lower extremity cases. None of the lower limb group suffered serious complications regardless of treatment, but all five upper limb cases did, four of them necessitating surgical intervention. Three of the five upper limb cases had a grave outcome with severe or permanent functional or neurological damage. CONCLUSION: Most post-catheterization pseudoaneurysms can be managed non-surgically. False aneurysms in the upper extremity are rare, comprising less than 2% of all lesions. However, upper extremity pseudoaneurysms present a potentially more serious complication and require early diagnosis and prompt intervention to minimize the high complication rate and serious long-term sequelae. Prevention can be achieved by proper puncture technique and site selection, and correct post-procedure hemostatic compression with or without an external device. Some upper limb lesions are avoidable if the axillary artery is not punctured.
The age distribution of a given national population is of utmost importance when dealing with public health and analyzing the use of various national health facilities. This is based on the totally different use of health sources by different age groups. Despite continuous prolongation of life expectancy and the related aging of the western hospitalized population the sub-group of patients over 100 year old of age is unusual demographically and accounts for only a very small portion of the total number of patients hospitalized in surgical wards. During the 5 year experience between 1995 and 2000 seventeen such patients were admitted to our surgical departments. Eight of those underwent 11 operations with zero peri-operative mortality and no significant complications. These 11 operations in this elderly population are the basis of our report.
The femoral artery remains the most used peripheral site for radiological catheter access. With a greater number of both diagnostic and therapeutic procedures being performed by interventional radiologists and cardiologists, and with larger catheters being used for stenting and endovascular grafting, the incidence of iatrogenic pseudo-aneurysms reported has reached as high as 0.5-2%. Ideally, they should thrombus spontaneously. However, when this does not occur, management options include: observation, ultrasound-guided obliterative compression, direct thrombin injection, embolization, stent graft insertion, and very rarely-surgery. During a 7-year period (1992-1999) we treated 131 cases of femoral artery false aneurysms. Until 1998 ultrasound-guided compression-obliteration, with a 95% success rate, was our method of choice. Since 1998, direct thrombin injection, with 100% success in 24 cases, has become our preferred method. It is pain-free, fully successful even in anticoagulated patients, and is currently our treatment of choice.
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Carotid endarterectomy is the most common vascular procedure. Recent studies have suggested that carotid endarterectomy can be performed safely, based solely on ultrasound duplex evaluation in selected patients. We evaluated 12 men and 8 women who underwent carotid endarterectomy, 12 for significant symptomatic disease and 8 for tight, asymptomatic stenosis of the carotid artery. All had duplex ultrasound scans without angiography before operation. They all survived. 2 had hoarseness due to vocal cord paralysis which resolved 5 months later in 1, while in the other it still persisted 2 months after operation. There were no other neurologic complications. During follow-up all have remained symptom-free. We conclude that clinical assessment of carotid artery stenosis with duplex ultrasound scan of good technical quality provides appropriate information on which to base carotid endarterectomy, and is a safe alternative to preoperative angiography.
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The following is presented to illustrate the importance of examining all peripheral pulses, especially the femoral pulse, before performing minor surgical procedures on the lower extremity, even limited toe amputation. This simple examination is a must in identifying patients at risk for severe peripheral arterial insufficiency, which can lead to major complications if underestimated or undiagnosed. We offer three examples to illustrate this point. All patients underwent successful revascularization and major lower limb amputation was avoided.
Hematocrit values, plasma fibrinogen levels, and erythrocyte deformability are well-recognized factors affecting blood viscosity. We studied the incidence of abnormalities in these factors among 17 patients suffering from thromboangiitis obliterans (Buerger's disease) compared with 14 normal age- and sex-matched control subjects. Hematocrit values and fibrinogen levels were higher, whereas the erythrocyte filterability index was lower among the patients with Buerger's disease (p less than 0.001). Incubation of washed erythrocytes from these patients with control plasma of blood type AB produced an improvement of the filterability index (p less than 0.005). Our findings suggest that patients suffering from Buerger's disease show, in addition to the well-recognized arterial lesions, an abnormality in the factors affecting blood viscosity. This may contribute to a worsening of the clinical manifestations. Evidence is presented suggesting that a plasmatic factor may be responsible for the impaired erythrocyte filterability.
Two unusual cases of delayed synthetic graft complications resulting from manufacturing defects of knitted Dacron are presented. Computed tomography appears to be a suitable noninvasive alternative examination to angiography in this condition.
A case of pseudoaneurysm of the cervical internal carotid artery secondary to tonsillectomy is presented and the pathogenesis of this vascular abnormality is discussed. Due to morphologic and inflammatory changes in the lateral pharyngeal wall, the entrapment aneurysm was maintained. The internal carotid artery was initially occluded above the carotid bifurcation. The transcatheter occlusion of the distal stump of this vessel, by steel coils, replaced a mutilating approach for exposure and ligation near the base of the skull.
A patient suffering from acute left subclavian artery thrombosis presented with an unusual syndrome of prominent somnolence, right cerebellar signs, and left upper extremity ischemia. Clinical, angiologic, and electrophysiologic studies confirmed a brain stem and reticular formation dysfunction due to vertebrobasilar ischemia. Urgent thromboembolectomy led to neurologic improvement and satisfactory revascularization of the involved upper limb.
Of 386 consecutive patients whose wounds were sutured at the emergency ward of the Soroka Medical Center, 228 returned for a follow-up visit during which pus was observed in 40 sutured wounds. Most of the patients were males, 50% lived in the city, and 13% were Beduin. Fifty percent of the wounds were dressed prior to admission. All wounds were rinsed prior to suture, 78% in a cetrimide-chlorhexidine HC1 solution and in 71% an irrigation with a povidone-iodine solution was performed. The physicians who performed the procedure were graded by their medical experience; 43% of the sutures were performed by interns, 32% by junior residents, 19% by senior residents and 6% by a specialist. Silk thread was the most commonly used suture material (79%). Wounds were classified according to size, depth and state of the margins of the wound. It was noted whether an excision was performed and the type of treatment that was prescribed after the procedure. None of the above-mentioned criteria identified a group as high-risk. Experienced physicians sutured the more serious wounds, but their infection rate did not differ significantly from other physicians.
A case of extensive injury to the left femoral artery and vein is presented. As circumstances did not permit the use of autogenous vein grafts, human umbilical cord vein grafts were used. Almost one year afterwards the patient is doing well and both grafts are patent.
The results of treatment of 101 combat injuries of the upper extremities are reported. There were 84 acute injuries and 17 late complications. There was a high incidence of associated fractures (35%) and nerve lesions (51%). Over half the injuries were repaired by saphenous vein graft replacement. There were seven early amputations related to a long delay before treatment, extensive tissue damage, and sepsis with delayed hemorrhage. There were no late amputations, but residual neurologic damage gave a less than perfect result in 32 extremities. Two injuries resulted in Volkmann's contracture. Fracture specific to the management of upper-extremity arterial injuries are outlined.
A series of 245 patients was operated upon for abdominal aortic aneurysm during the years 1969-77, of whom 162 were elective cases while in 83 the aneurysm was leaking or had ruptured. The hospital mortality for the latter group fell from 77 per cent at the beginning of the study period to 30 per cent at the end. For elective operations, hospital mortality averaged 9.3 per cent, though during the last 2 years there were no deaths in the 51 consecutive cases. Operative methods and postoperative treatment changed during the years of the study, with few excision-replacement grafts and greater use of the inlay technique, most of the latter being simple unbranched Dacron tubes. Early graft infection, the most important and serious surgical complication, caused 9 deaths, an overall incidence of 3.7 per cent, of which 8 were in patients who received no perioperative antibiotics and only 1 among the patients who did receive them. All deaths were in the inlay group. The reasons for this are discussed. Since July 1976 perioperative antibiotic treatment has been routine for all arterial prosthetic graft patients in our hospital.
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