Mammography of breasts in which catheter cuffs have been retained: normal, infected, and postoperative appearances

OBJECTIVE: The purpose of this report is to show that Dacron (DuPont, Wilmington, DE) cuffs retained in breasts after the removal of Hickman catheters may result in complications requiring radiographic evaluation for subsequent management. We also describe potential complications, including infection, associated with a retained cuff and changes after the removal of a retained cuff. CONCLUSION: Because of the increased use of Hickman catheters for central vein access, Dacron cuffs more frequently are retained in breasts and are likely to be seen on mammograms. Radiologists need to be aware of the mammographic findings of a normal cuff, infected cuff, and the site of a surgically excised cuff.     

Surgical treatment of threatened reversed infrainguinal vein grafts

PURPOSE: Current information concerning the results of surgical revision of threatened infrainguinal vein grafts is largely limited to in situ conduits. Infrainguinal grafts may be threatened by intrinsic graft lesions or significant stenosis in the adjacent inflow or outflow arteries. To assess the results of operative revision of infrainguinal reversed vein grafts, we reviewed our experience with surgical revision of threatened infrainguinal reversed vein grafts identified through a program of postoperative clinical and vascular laboratory graft surveillance. METHODS: All patients who underwent surgical revision of a threatened but patent infrainguinal reversed vein graft from January 1987 through April 1993 were identified through review of our vascular registry. Data were analyzed for type of vein used, date of original reversed vein graft, clinical and vascular laboratory findings leading to reversed vein graft revision, results of preoperative angiography, patient risk factors, operative techniques and complications, and long-term assisted primary graft patency and limb salvage. RESULTS: Ninety-six patients with 100 infrainguinal reversed vein grafts (69) femoral-popliteal, 31 femoral-tibial) underwent 117 surgical vein graft revisions or inflow procedures during the study period. Eighty-one percent of the original reversed vein grafts consisted of a single segment of greater saphenous vein. All revised grafts had at least a 50% stenosis in the graft itself or the proximal or distal artery. A single revision was performed in 85 grafts, two revisions in 13 grafts, and three revisions in two grafts. There were nine (8%) isolated inflow procedures, eight (7%) vein patch angioplasties, 62 (53%) interposition vein grafts, and 29 (25%) vein graft extensions to a new distal anastomotic site. The remaining nine (8%) procedures consisted of combinations of the above. Median time to primary graft revision after initial graft implantation was 15 months (range 2 days to 316 months). Mean time to secondary revision after primary revision was 21 months. Operative mortality was 0.9%. Cumulative assisted primary patency of the original grafts revised for stenotic lesions was 99%, 96%, and 92% at 1, 3, and 5 years, respectively. Limb salvage was 99%, 97%, and 97% at 1, 3, and 5 years, respectively. CONCLUSIONS: Although surgical revision of reversed vein graft requires much use of alternative vein sources, these procedures can be performed with minimum mortality and provide excellent assisted primary graft patency and limb salvage.     

The development of valvular incompetence after deep vein thrombosis: a follow-up study with duplex scanning

PURPOSE: Duplex ultrasonography with distal cuff deflation was used to establish the physiologic reflux duration in different segments of the deep venous system in healthy individuals, and to document the occurrence of deep vein valve incompetence in patients after deep vein thrombosis (DVT). METHODS: Two hundred fifty-two vein segments in 42 legs of 21 healthy individuals and 160 deep vein segments in 27 patients with phlebographically documented DVT were examined with duplex scanning. RESULTS: The duration of reflux in healthy subjects was significantly shorter in distal deep vein segments. Ninety-five percent of the values were less than 0.88, 0.8, 0.8, 0.28, 0.2, and 0.12 seconds, respectively, for the common femoral, superficial femoral, deep femoral, popliteal, and posterior tibial vein (at midcalf and ankle level). The 95 percentile for reflux duration in the superficial venous system was 0.5 seconds for all vein segments, regardless of the location. No significant correlation was found between the reflux peak flow velocity and reflux duration (R = 0.6). The reflux peak flow velocity is therefore not useful as a parameter of the degree of reflux. The patient group was examined with an interval of 18 to 51 months (mean 34 months) after DVT. Forty-five percent of the initially affected segments showed valve incompetence at follow-up (n = 54); only three of 40 segments initially free from thrombus showed pathologic reflux at follow-up (p < 0.01). Reflux durations in most of the incompetent vein segments were two or more times the normal value of reflux duration. The highest prevalence of valve incompetence was found in the superficial femoral and popliteal vein segment (p < 0.01). None of the patients showed valve incompetence at all levels of the deep venous system. A significant (p = 0.04) relation was found between the extent of the initial thrombosis and the number of refluxing vein segments at follow-up, but no correlation was found between the extent of initial thrombosis and the late clinical symptoms (p = 0.16); clinical symptoms could not be related to the number of incompetent vein segments. CONCLUSIONS: Duplex scanning allows a good discrimination between physiologic and abnormal reflux duration and is an important tool in the evaluation of the postthrombotic limb. Early assessment after DVT may have prognostic value in individual patients.     

Circular intestinal and esophageal suture with universal suture device (experimental trial)

A universal suture device (USD) able to make simultaneous two-line and cross-shaped circular clips stitches on various tube-shaped organs (vessels, intestines, esophagus, stomach, ets), creating end-to-end and end-to-side anastomosis with the external cuff is proposed. The results of experimental trials of USD and its clinical use in anastomosing main vessels were published before (8, 9, 11, 12). In this article the results of experiments with the use of USD in intestinal and esophageal sutures in 35 dogs are analysed. There were 4 series of experiments with 45 anastomoses (31 intestinal and 14 esophageal anastomoses). The anastomosed segments of the intestines and esophagus healed at the level of the lower side of the cuff. The cuff completely resumes its shape in 2.5-5 months, and the clips come off by month 7-8 after the surgery. The mucous layer of the esophagus straightened by the 2-3d month, while adventitial-muscular layer does not straigheten at all, and the clips from it could be found till the 10th month after the surgery. There were no cases of anastomotic incompetence.     

Multiple level arterial occlusions of the leg. Reliability of indirect thigh pressures in the assessment of proximal arterial obstruction

19 patients with obstructive arterial disease both proximal and distal to the inguinal ligament were studied with segmental blood pressure recordings because reconstruction of the proximal lesion was considered. The common femoral pressure was measured intraarterially as well as with a 12 cm cuff placed as proximally as possible on the thigh. The proximal pressures measured by the two techniques were found to correlate well. Thus, the atraumatic cuff pressure technique is validated which can be of use in evaluating multilevel occlusions and the associated run off problem involved in partial proximal reconstruction.     

Insulin resistant diabetes mellitus without the presence of insulin antibodies. A case report

Despite a high patency rate and low incidence of infections, several complications have been described with the Brescia subcutaneous arteriovenous fistula. We recently observed five patients with swelling of the hand and wrist secondary to increased distal vein flow. Ligation of the distal vein, with or without proximal reconstruction resulted in cure. Proximal vein patency must be assessed.     

Predictors and sequelae of distal embolization during saphenous vein graft intervention from the CAVEAT-II trial. Coronary Angioplasty Versus Excisional Atherectomy Trial

BACKGROUND: The purpose of this study was to identify the predictors and sequelae of distal embolization from a multicenter, randomized trial of saphenous vein graft intervention. The CAVEAT-II trial demonstrated that saphenous vein graft directional coronary atherectomy (DCA) was associated with greater angiographic success and less need for repeat intervention compared with percutaneous transluminal coronary angioplasty (PTCA) but at the cost of more acute complications--notably distal embolization. METHODS AND RESULTS: In CAVEAT-II, 305 patients were randomly assigned to DCA (149 patients) or PTCA (156 patients) for lesions with > 60% diameter stenosis in vein grafts > or = 3 mm in diameter. Distal embolization occurred in 20 patients (13.4%) assigned to DCA and 8 patients (5.1%) assigned to PTCA (P = .011). Independent predictors of distal embolization were use of DCA (71% in distal embolization patients versus 47% in patients without distal embolization, P = .011) and presence of thrombus (39% in distal embolization patients versus 14% in patients without distal embolization, P < .00). In-hospital adverse events were more frequent after distal embolization; 71% versus 20%, odds ratio plus (95% confidence intervals) 9.87 (4.65, 20.94). At 12-month follow-up, adverse event rates were also higher in patients with distal embolization (odds ratio, 3.05 [1.95, 4.76]). CONCLUSIONS: In this first prospective multicenter trial of saphenous vein graft intervention, distal embolization was more common after DCA than PTCA and in lesions containing thrombus. It also was associated with worse in-hospital and 12-month outcomes. The risk and sequelae of distal embolization should be considered when choosing a treatment strategy for vein graft disease.     

Infrapopliteal bypasses to severely calcified, unclampable outflow arteries: two-year results

PURPOSE: Although severe, circumferential calcification of distal outflow vessels is frequently encountered, its effect on bypass graft patency rates has not been well established. METHODS: Using a computerized vascular registry database, we conducted a retrospective review of 1957 bypass grafts with distal anastomoses to infrapopliteal vessels performed at a single institution between 1990 and 1995. Of these cases, 101 procedures involved outflow arteries classified by the operating surgeon as severely calcified and unclampable (requiring intraluminal occluders for vascular control), whereas in 105 cases the outflow arteries had no calcification present at the distal anastomotic site. The remaining cases had varying intermediate degrees of calcification and were not analyzed. Indication for bypass procedure was limb-threatening ischemia in 90% of severe calcification cases and in 84% of cases without calcification. Atherosclerotic risk factors were similar except for the presence of diabetes (92% vs 74%, p < 0.001), creatinine level > 2.0 mg/dl (21% vs 8%, p < 0.01), and dialysis dependency (17% vs 3%, p < 0.001), all of which were more prevalent in the severe calcification group. Infrapopliteal distal anastomotic location and type of conduit ( > 90% autogenous vein) were comparable between groups. RESULTS: Primary patency, secondary patency, and foot salvage rates at 24 months were 60%, 65%, and 77% for the severe calcification group and 74%, 82%, and 93% for the no calcification group, respectively. With secondary procedures comprising 26% of cases in each group, data from the 150 primary procedures were reanalyzed separately. In this primary procedure group, 24-month primary patency, secondary patency, and foot salvage rates were 66%, 69%, and 77% for the severe calcification group and 84%, 90%, and 96% for the no calcification group, respectively. Although patency and salvage rates were consistently lower for the severe calcification group in all analyses, these differences did not achieve significance by log-rank life-table analysis at 2-year follow-up. Perioperative 30-day mortality (0.99% severe calcification vs 0.95% no calcification) and 24-month survival rates (84% severe calcification vs 83% no calcification) were also similar between groups. CONCLUSION: These data suggest that effective techniques exist to perform infrapopliteal bypasses to severely calcified, unclampable outflow arteries with results comparable with those obtained with clampable, uncalcified vessels. The finding of severe, circumferential calcification of outflow target arteries should not dissuade vascular surgeons from distal bypass for limb salvage indications.     

A novel technique for management of the en bloc bladder cuff and distal ureter during laparoscopic nephroureterectomy

PURPOSE: The optimal technique of excising the juxtavesical ureter and bladder cuff during laparoscopic nephroureterectomy is still evolving. We report on a novel transvesical needlescopic (2 mm. instrumentation) assisted technique of en bloc retrieval of the juxtavesical ureter and bladder cuff during laparoscopic radical nephroureterectomy for upper tract transitional cell carcinoma. MATERIALS AND METHODS: Retroperitoneal laparoscopic nephroureterectomy was performed in 8 patients using this technique. Two needlescopic ports (2 mm.) inserted suprapubically into the bladder were used in combination with a cystoscopically positioned Collins knife. RESULTS: Satisfactory circumferential detachment of the bladder cuff and en bloc mobilization of 3 to 4 cm. of the intact pelvic extravesical ureter were achieved transvesically in each case in a manner comparable to open surgery. CONCLUSIONS: This technique simulates established open surgical principles of treating the distal ureter during laparoscopic nephroureterectomy.     

Can duplex scan arterial mapping replace contrast arteriography as the test of choice before infrainguinal revascularization?

PURPOSE: Arteriography is the diagnostic test of choice before lower extremity revascularization, because it is a means of pinpointing stenotic or occluded arteries and defining optimal sites for the origin and termination of bypass grafts. We evaluated whether a duplex ultrasound scan, used as an alternative to arteriography, could be used as a means of accurately predicting the proximal and distal anastomotic sites in patients requiring peripheral bypass grafts and, therefore, replace standard preoperative arteriography. METHODS: Forty-one patients who required infrainguinal bypass grafts underwent preoperative duplex arterial mapping (DAM). Based on these studies, an observer blinded to the operation performed predicted what operation the patient required and the best site for the proximal and distal anastomoses. These predictions were compared with the actual anastomotic sites chosen by the surgeon. RESULTS: Whether a femoropopliteal or an infrapopliteal bypass graft was required was predicted correctly by means of DAM in 37 patients (90%). In addition, both anastomotic sites in 18 of 20 patients (90%) who had femoropopliteal bypass grafts and 5 of 21 patients (24%) who had infrapopliteal procedures were correctly predicted by means of DAM. CONCLUSION: DAM is a reliable means of predicting whether patients will require femoropopliteal or infrapopliteal bypass grafts, and, when a patient requires a femoropopliteal bypass graft, the actual location of both anastomoses can also be accurately predicted. Therefore, DAM appears able to replace conventional preoperative arteriography in most patients found to require femoropopliteal reconstruction. Patients who are predicted by means of DAM to require crural or pedal bypass grafts should still undergo preoperative contrast studies to confirm these results and to more precisely locate the anastomotic sites.     

Trace elements in egg contents and egg shells of slider turtles (Trachemys scripta) from the Savannah River Site

OBJECTIVES: Stricture of the vesico-urethral anastomosis is a well-known complication after radical prostatectomy. Dilatation, stricture incision or resection have been proposed for endoscopic treatment. METHODS: In a retrospective study of 340 patients with prostatic cancer who underwent a radical retropubic prostatectomy from 1988 until 1996, we looked at the incidence of anastomotic strictures. RESULTS: An anastomotic stricture was found in 24 cases (7%) requiring endoscopic treatment. Based on prospective X-ray studies, we were able to show that the site of stricture is located below the bladder neck musculature in most cases well above the distal urethral sphincter and pelvic floor. No continence problems were encountered following structure resection in a follow-up of 12-72 months determined by a questionnaire and pad test. CONCLUSION: The transurethral resection of anastomotic stricture allows for a rather generous tissue resection, which is preferable to incision or dilatation in our hands.     

Catastrophic complications of the cervical esophagogastric anastomosis

Recent enthusiasm for the cervical esophagogastric anastomosis has arisen because of its perceived low morbidity. Although catastrophic complications of a cervical esophagogastric anastomosis are unusual, they can and do occur, and prevention is possible if the potential for them is recognized. Among 856 patients undergoing a cervical esophagogastric anastomosis after transhiatal esophagectomy, catastrophic cervical infectious complications occurred in 11 patients (1.3%): vertebral body osteomyelitis (1), epidural abscess with neurologic impairment (2), pulmonary microabscesses from internal jugular vein abscess (1), tracheoesophagogastric anastomotic fistula (1), and major dehiscence necessitating anastomotic takedown (6). These complications became manifest from 5 to 85 days after the esophageal resection and reconstruction (mean 19 days). Leakage from a gastric suspension stitch placed in the anterior spinal ligament over the vertebral bodies resulted in a posterior gastric leak and either osteomyelitis or an epidural abscess in three patients, none of whom had evidence of extravasation on the routine barium swallow 10 days after operation. Cervical exploration for a presumed anastomotic leak led to the unexpected discovery of an abscess formed by the stomach and the adjacent wall of the internal jugular vein, which was ligated and resected. One patient without symptoms who was discharged from the hospital with a contained anastomotic leak on the postoperative barium swallow was readmitted 7 days later with a cervical tracheoesophagogastric anastomotic fistula of which he ultimately died. In 6 patients (7% of those who had anastomotic leaks) there was sufficient gastric ischemia or necrosis, or both, to necessitate takedown of the anastomosis and intrathoracic stomach, cervical esophagostomy, and insertion of a feeding tube. As a result of this experience, it is recommended that cervical gastric suspension sutures either be omitted entirely or placed in the fascia over the longus colli muscles anterior to the spine, but not directly into the prevertebral fascia overlying the vertebral bodies or cervical disks. All but minute cervical anastomotic leaks, even if apparently contained, are best drained rather than treated expectantly. Patients who remain febrile and ill after bedside drainage of a cervical esophagogastric anastomosis leak should undergo cervical reexploration in the operating room; major gastric ischemia or necrosis, or both, may warrant takedown of the anastomosis and intrathoracic stomach.     

An in vitro study of tracheostomy tube cuff herniation and inflation characteristics

Seven of the most commonly used tracheostomy tubes used in the UK were tested for cuff herniation and creasing in synthetic tracheas corresponding to the shapes and sizes found in vivo. Results demonstrated that only two tubes of one particular brand herniated and that creasing occurred in tubes disproportionately large for the trachea used. A discussion of modern tracheostomy tube manufacture is included.     

Histological and morphometric analyses of early and late aortocoronary vein grafts and distal anastomoses

BACKGROUND: Aortocoronary vein grafts develop fibromuscular intimal hyperplasia within the first year of implantation. Tissue remodeling may promote development of graft atherosclerosis and thrombosis. Angiographic studies show that human aortocoronary vein grafts in situ for one or more years become stenosed, preferentially at the distal anastomosis versus the body or trunk of the graft or at the proximal anastomosis. Previous studies have not reported morphological data on the nature and distribution of intimal lesions around the distal graft/artery anastomoses. OBJECTIVE: To examine and quantify histological and morphometric changes within the intima of 27 aortocoronary vein grafts and their distal anastomoses. METHODS: Seventy-two hearts obtained at autopsy and one at heart transplantation were examined, photographed and fixed in 10% buffered formaldehyde solution. Three to seven 3 mm long segments of grafts and their distal anastomoses were sectioned, stained and examined by light microscopy. RESULTS: Eleven early grafts were implanted for six weeks or less, and they showed significant cellular hyperplasia mainly at the suture line. In 16 late grafts in situ 1.5 to 15 years, the degree of fibromuscular intimal thickening was greatest on the hood and at the suture line, whereas on the floor of the native artery and in the graft body the degree of thickening was approximately one-third and two-thirds, respectively, that seen on the hood. CONCLUSIONS: Stenosis of aortocoronary vein grafts at their distal anastomosis is likely related to the preferential development of intimal thickening on the hood of the graft and at the suture line. Because fibromuscular intimal hyperplasia has been reported to play a role in the development of atherosclerosis and thrombosis in the body of vein grafts, this focal hyperplasia at the distal anastomosis may also play a role in vein graft failure.     

Anatomical differences in responsiveness to vasoconstrictors in the mesenteric veins from normal and portal hypertensive rats

The present study evaluates the effects of pre-hepatic portal hypertension, induced in rats by partial portal vein ligation, on the responsiveness of rostral (proximal) and caudal (distal) rings from the mesenteric vein. The anatomical origin of the sample influenced the response to vasoconstrictors in sham-operated animals, and this pattern of reactivity was specifically modified in portal-ligated rats. In veins from sham-operated rats, contraction induced by a submaximal concentration of KCl (60 mM) was greater in proximal than in distal rings. Vasopressin and 5-hydroxytryptamine contracted mainly distal rings, methoxamine showed a greater effect on proximal rings, and endothelin-1 and angiotensin-II contracted vein rings independently of their anatomical origin. In veins from portal hypertensive rats, response to KCl (60 mM) were increased in distal rings, and all rings exhibited enhanced reactivity to vasopressin and 5-hydroxyptyptamine as well as attenuation of the response to methoxamine. Responses to endothelin-1 were decreased in proximal vein rings from portal hypertensive rats whereas responses to angiotensin-II were not influenced by the anatomical origin. Incubation with atropine, propranolol or indomethacin, did not modify the responses to vasopressin and 5-hydroxytryptamine in tissues from either sham-operated or portal hypertensive animals. Likewise, the hyporeactivity to methoxamine and endothelin-1 in rings from portal hypertensive rats persisted in the presence of the nitric oxide inhibitor NG-nitro-L-arginine methyl ester. These results suggest the physiological existence of anatomical differences in the responsiveness to vasoconstrictors throughout the mesenteric vein and that changes in the responsiveness of the mesenteric vein induced by portal hypertension are specific for each agonist and possibly result from individual variations at a receptor or post-receptor level.     

Prevention of focal intimal hyperplasia in rat vein grafts by using a tissue engineering approach

The present study focused on the role of blood flow in the formation of focal intimal hyperplasia in vein grafts, as well as the development of an engineering approach that can be used to eliminate disturbed blood flow and prevent blood flow-related focal intimal hyperplasia. A rat vein graft model was constructed by interposing a jugular vein into the abdominal aorta with end-to-end anastomoses. Locally disturbed flow was identified by analyzing particle streak-lines in methyl salicylate-cleared and perfused vein grafts in vitro with a physiological Reynolds number. At day 10, 20, and 30 after surgery, focal intimal hyperplasia of the vein grafts was examined using a histological approach and the density of alpha-actin positive cells was determined using immunohistological and fluorescent approaches. Results showed that apparent eddy blood flow formed at the proximal, but not at the distal, end of the vein grafts due to graft-host diameter mismatch and local geometric distortions, and was associated with apparent focal intimal hyperplasia. The thickness of the alpha-actin positive layers of the proximal vein grafts was significantly higher than that of the distal grafts (192 +/- 27 vs. 94 +/- 18 microm, 278 +/- 55 vs. 124 +/- 20 microm, and 288 +/- 24 vs. 131 +/- 23 microm for day 10, 20. and 30, respectively). The density of the alpha-actin positive cells, however, was similar between the proximal and the distal regions (3569 +/- 361 vs. 3285 +/- 343 cells/mm2, 5540 +/- 650 vs. 5376 + 887 cells/mm2, and 5465 +/- 791 vs. 5278 +/- 524 cells/mm2 for day 10, 20, and 30, respectively). When eddy blood flow was eliminated by matching the graft-host diameters using a tissue engineering approach, the average thickness of the alpha-actin positive layers of the proximal (71 +/- 15, 86 +/- 16, and 85 +/- 14 microm for day 10, 20, and 30, respectively) and the distal vein grafts (68 +/- 13, 80 +/- 14, and 79 +/- 13 microm for day 10, 20, and 30, respectively) was reduced significantly. The density of the alpha-actin positive cells was also reduced significantly in the proximal (2946 +/- 359, 3261 +/- 295, 3472 +/- 599 cells/mm2 for day 10, 20, and 30, respectively) and in the distal regions (3151 +/- 511, 3466 +/- 687, 3593 +/- 688 cells/mm2 for day 10, 20, and 30, respectively). The thickness of the alpha-actin positive layers and the density of the alpha-actin positive cells were not significantly different between the proximal and distal regions of the engineered vein grafts at each observation time. These results suggest that eddy flow may develop in vein grafts and may facilitate the formation of focal intimal hyperplasia, and the vascular tissue engineering approach developed in this study may be used to prevent blood flow-related focal intimal hyperplasia in vein grafts.     

Thrombin-antithrombin III complex in acute retinal vein occlusion

PURPOSE: To determine whether quantitative differences in systemic hypercoagulable state could be identified among patients with retinal vein occlusion at various sites of occlusion. METHODS: The value of thrombin-antithrombin III complex was determined in 57 patients with retinal vein occlusion within 1 month after the subjective onset of retinal vein occlusion and in 15 age-matched normal controls. RESULTS: Levels of log thrombin-antithrombin III complex were significantly higher in the patients with proximal retinal vein occlusion in which the occlusion site is at the optic disc (mean +/- SD, 0.493 +/- 0.389) than in those with distal retinal vein occlusion in which the occlusion site is away from the optic disc (0.312 +/- 0.150, P = .025) and in the normal controls (0.294 +/- 0.151, P = .020). There was no significant difference between the distal retinal vein occlusion and the normal controls (P = .720). More patients with proximal retinal vein occlusion showed elevated thrombin-antithrombin III complex values more than 3.9 ng/ml than those with distal retinal vein occlusion (8/29 vs 1/28, P = .025). Of nine patients showing an initial value of thrombin-antithrombin III complex of more than 3.9 ng/ml, repeated measurements were obtained in eight patients, who showed reduced value of thrombin-antithrombin III complex in the normal range in several months. CONCLUSIONS: A systemic hypercoagulable state, which could be demonstrated with the elevation of thrombin-antithrombin III complex value, may contribute more to the development of retinal vein occlusion with thrombus at or near the trunk of the central retinal vein than those with thrombus at branch veins away from the optic disc in the retina.     

Successful treatment of an infected pseudoaneurysm of the ascending aorta with omental transfer--a case report

The formation of pseudoaneurysm is an uncommon complication of after coronary artery bypass grafting (CABG). We report a 66-year-old man in whom an anastomotic pseudoaneurysm of the ascending aorta derived from mediastinitis after repeat CABG. At operation, the pseudoaneurysm was revealed to be involved in the proximal anastomotic site of a saphenous vein graft to the RCA. The aneurysm was resected and the defect was repaired with woven dacron patch under deep hypothermic circulatory arrest. In addition, omental transposition was performed to treat mediastinitis radically. Debris of the pseudoaneurysm grew methicillin-resistant Staphylococcus aureus (MRSA), so vancomycin was administered intravenously for 8 weeks. The postoperative course was uneventful. We considered that omental transfer can be very effective in the management of severe mediastinitis, especially that due to an infected pseudoaneurysm or widespread mediastinitis caused by MRSA.     

Intra-operative measurement of the tissue blood flow for evaluating blood supply to the gastric tube for esophageal reconstruction

BACKGROUND/AIMS: Anastomotic leakage after esophageal surgery is still the main reason for post-operative morbidity and mortality. We developed a reliable procedure for evaluating blood supply to the gastric tube after esophageal reconstruction. METHODOLOGY: After construction of the gastric tube, tissue blood flow was measured intra-operatively at the anastomotic sites using laser Doppler flowmetry. RESULTS: There was a distinct difference in tissue blood flow at the distal portion of the gastric tube. The tissue blood flow at the sites of attempted anastomosis was considerably decreased compared to the value of the gastric body (control site). CONCLUSIONS: By measuring tissue blood flow at the attempted anastomotic site intra-operatively using laser Doppler flowmetry, a sufficiently nourished gastric tube could be prepared. It was our hypothesis that total elimination of the ischemic portion would make esophagogastric anastomosis safer and more reliable.     

Postpartum ultrasonographic diagnosis of inferior vena cava thrombus associated with ovarian vein thrombosis

Postoperative ultrasonographic assessment as a result of unremitting fever after cesarean section depicted a large pedunculated thrombus within the inferior vena cava at the level of the right renal vein. Subsequent imaging studies revealed that this thrombus was the distal extension of right ovarian vein thrombosis into the inferior vena cava.