Biomedical subjects

R D Kohl

Publications and source records attributed to R D Kohl.

8 recordsLinked to original sources

PubMed1992

Spontaneous peripheral arterial microembolization.

Over a seven year period 52 patients having a clinical diagnosis of spontaneous peripheral arterial microembolization were identified. Sixty-one percent of patients were female, 15% were diabetic, and 73% used tobacco chronically. A striking finding was the very high incidence of associated systemic disorders such as thrombocytosis (8), polycythemia vera (3), metastatic adenocarcinoma (3), or collagen disease requiring steroid therapy (4). Forty-nine patients had significant proximal arterial lesions as the origin of their emboli. Three patients had digital ischemia as a result of increased platelet aggregation without arterial obstruction. Forty-eight patients underwent surgical therapy. Operative mortality was 4% and overall limb salvage in survivors was 96%. The clinical syndrome of arterial microembolization may result from several pathophysiologic mechanisms including cholesterol embolization from ulcerated plaques, fibrino-platelet aggregation in patients with hematologic disorders, or dislodgement of mural thrombus in those with aneurysmal disease. We observed aortoiliac disease to be more frequent than femoral-popliteal disease, and both were amenable to surgical correction. We conclude that the genesis of arterial microembolization is multifactorial and that a variety of systemic diseases may work in concert with atherosclerotic arterial disease to produce this clinical syndrome. Prompt recognition and appropriate treatment of this disorder can yield high rates of limb salvage.

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PubMed1992

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.

Adult↗

PubMed1992

Salmonella infections of the abdominal aorta.

Salmonella accounts for up to one-third of all primary abdominal aortic infections. During the past ten years, we have treated three patients with this disease and have reviewed an additional 61 instances found in the English literature. The overall survival rate was 46 percent. Fever and back or abdominal pain were present in more than 90 percent of the patients, while a pulsatile mass was present in only 42 percent of those reported. Blood cultures were positive in 73 percent of patients. Computed tomography and angiography were helpful in delineating the presence of aneurysms and defining the extent. Twenty-two patients were treated without undergoing aortic resection; there were no survivors. One patient had an aortic resection without reconstruction and survived. Twenty-eight patients were treated with aortic resection and anatomic reconstruction. Six patients in this group died of graft sepsis and an additional six patients required graft removal for persistent infection. In contrast, 18 of 19 patients treated with extra-anatomic grafting and aneurysm resection survived, with only one death from aortic stump sepsis. No patient has required graft removal for sepsis. These results suggest that aneurysm resection and extra-anatomic bypass is the treatment of choice in patients with Salmonella infections involving the infrarenal aorta.

Aged↗

PubMed1990

Surgical procedures in the management of Takayasu's arteritis.

Takayasu's 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 Takayasu's 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 Takayasu's arteritis frequently requires arterial reconstruction. Symptomatic improvement and excellent long-term graft patency can be expected after arterial reconstruction.

Adolescent↗

PubMed1987

Mycotic suprarenal aortic aneurysm.

Two cases of mycotic suprarenal aortic aneurysm treated by anatomic reconstruction are presented. Diagnosis was facilitated by 67-Gallium Citrate Scanning, Computer Assisted Tomography (CT), and Angiography. Increasing symptoms with attenuation of the aortic wall identified by CT necessitated urgent resection and reconstruction in both patients. Contained rupture of the aneurysm was found in one patient. Cultures of the resected tissue grew Salmonella dublin and Bacteroides fragilis. The patients were treated with continuous antibiotic therapy. Follow-up demonstrated asymptomatic patients with sterile blood cultured and good anatomic results on CT at one year. No recurrent sepsis nor aneurysmal dilatation is evident to date. Based on our experience and the available literature we conclude that inline reconstruction is the method of choice for treatment on these lesions.

Aged↗

PubMed1976

Vascular manifestations of the thoracic outlet syndrome. A surgical urgency.

Although the vascular manifestations of the thoracic outlet syndrome are infrequent, their presence is an ominous portent for the affected limb. The cases of two recent patients indicate the importance of prompt recognition, urgent angiography, and definitive surgery. Regarding the surgical procedure, we used a two-incision approach-supraclavicular and intraclavicular-combining scalenotomy, resections of the cervical rib if present, the first thoracic rib, and the subclavian artery with retroclavicular interposition woven Dacron graft reconstruction. Preceding graft replacement, a Fogarty catheter thrombectomy of the distal brachial artery tree is done with completion arteriography to ensure freedom from retained distal thrombus. First rib resection is easily performed; subsequent vascular repair is also carried out, using this approach. We did not add sympathectomy to these cases, believing that early recognition and treatment will obviate its necessity. Follow-up has supported the efficacy of the treatment plan as presented.

Adult↗

PubMedDate not supplied

Compartmental syndromes in which the skin is the limiting boundary.

Following closed fasciotomy, skin may become the limiting boundary of extremity swelling. The resulting increase in pressure within the limb may threaten its survival. Realizing this potential complications, we reserve closed fasciotomy for those cases in which only moderate swelling is anticipated. Following this procedure the patient is observed closely for evidence that decompression dermotomy is indicated. Patients in whom severe swelling is present or anticipated are treated with fasciotomy and primary dermotomy. Wounds are closed by either primary or delayed skin graft. This approach has proven useful in the management of traumatized or vascularly embarrassed limbs in which swelling may compromise extremity viability.

Adult↗

PubMedDate not supplied

Spontaneous rupture of an aortic aneurysm into the left renal vein. A diagnostic challenge.

Rupture of an aortic aneurysm into a renal vein presents a rare and difficult diagnostic problem. Often, therapy is delayed because the patient is thought to have a urologic problem. In this instance, CT scan provided useful clues leading to the diagnosis of this entity, and its rapid treatment. To our knowledge, this is the first CT scan done in a patient with aorto-renal vein fistula.

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