Pelvic fracture with shock-inducing retroperitoneal bleeding and concomitant lower extremity ischemia syndrome: discussion of management exemplified by a case report

BACKGROUND: Initial treatment of severe pelvic fracture consists of appropriate resuscitation and early pelvic reposition and stabilization. Concomitant retroperitoneal arterial bleeding in a hemodynamically unstable patient in combination with lower extremity ischemia make early management decisions very difficult and the mortality rate of this entity of injuries is extremely high. CASE REPORT: We report on a successful treatment of a 36 year old skier, referred in hemorrhagic shock, who had sustained a severely displaced both column fracture of the right acetabulum, an unstable pelvic ring injury on the left and a retroperitoneal bladder rupture. He developed complete ischemia of the right lower extremity. Angiography revealed an obliteration without extravasation of the external iliac artery and allowed treatment of a right superior gluteal artery disruption by embolization. The right lower extremity ischemia was revascularized with a subcutaneous femoro-femoral bypass graft. Delayed internal fixation of the right acetabulum and exploration of the iliac vasculature was done through an ilio-inguinal approach. Simultaneously, the cross-over bypass could be removed. After 18 months, the patient recovered without any ischemic symptoms, but continues with a mixed sciatic nerve lesion. DISCUSSION AND CONCLUSIONS: The combination of severe retroperitoneal arterial bleeding and total ischemia of the lower extremity requires immediate surgical therapy. Direct exploration of the retroperitoneum, however, can be fatal and should be avoided if the iliac vessels are angiographically intact or if a hemorrhage is controllable by an embolization procedure. Extraanatomic temporary revascularization of the lower extremity should be envisaged when a lower leg ischemia due to obliteration or compression of major intrapelvic vessels cannot be directly and immediately treated.     

Alternatives in the management of penetrating injuries to the iliac vessels

BACKGROUND: The high mortality and morbidity rates after iliac vessel injuries remain a challenging problem for trauma surgeons. Several controversial issues surround the management of iliac vessel injuries, including the value of abbreviated laparotomy, the role of extra-anatomic bypass reconstruction (EABR), the use of vascular prostheses in the presence of contamination, and the need and timing for fasciotomy. METHODS: Retrospective review of the records of patients who sustained an injury to the iliac vessel between 1987 and 1996. RESULTS: A total of 64 patients were treated, including 23 with isolated iliac vein injuries, 17 with arterial injuries, and 24 with combined arteriovenous injuries. Vascular prostheses were placed in 17 patients with arterial injuries, including 12 with associated intestinal wounds. Graft infection did not occur. Of the 24 patients with combined injuries, 11 underwent abbreviated laparotomy and 1 died. Five deaths, however, occurred in 13 patients in whom no attempts were made for damage control laparotomy. Significant differences between survivors and nonsurvivors included final arterial pH, final prothrombin time, length of hypotension, and number of transfusions. Arterial ligation with EABR was performed in five patients and failed in two. Deep venous thrombosis and pulmonary embolism occurred in four patients, in three of them after venous injuries were ligated. The overall mortality rate was 23%. CONCLUSION: Our findings show that (1) abbreviated laparotomy reduces mortality in iliac injuries; (2) EABR should be performed early after stabilization to prevent limb ischemia; (3) the use of vascular prostheses with associated intestinal injuries did not appear to increase the incidence of graft infection; and (4) after vein ligation, early fasciotomy and prophylaxis against extremity swelling, deep venous thrombosis, and pulmonary embolism should be considered.     

Compartment syndrome

Compartment syndrome most commonly occurs following revascularization of an acutely ischemic extremity. It is not only a danger for patient's extremity but also for his or her life if it is not detected and treated in time. The authors present 37 patients treated during 10-years period at the Department of Surgery, University Hospital in Pilsen for compartment syndrome after acute extremity ischemia due to arterial occlusion or trauma. Twenty-five (67.6%) patients healed without complication. Amputation and mortality rate was 16.2%. The main cause of patient's death was reperfusion injury. The length of ischemia and time of fasciotomy were statistically significant factors for the result of treatment. The authors emphasize the significance of early diagnosis and treatment of compartment syndrome.     

Retrograde iliofemoral endarterectomy facilitated by balloon angioplasty

PURPOSE: The purpose of this study was to explore the feasibility of iliofemoral endarterectomy performed through a single groin incision. METHODS: Thirty-two patients aged 34 to 75 years (mean age 63.4 years) with a male/female ratio of 20:12 underwent 36 lower extremity inflow reconstructions from July 1989 to September 1994. Surgical indications were for limb-threatening ischemia in 24 patients and for claudication in eight patients. The procedures were done for occlusive disease of the external iliac artery and common femoral artery with patients under either spinal (n = 24) or local (n = 12) anesthesia. Intraoperative balloon angioplasty with fluoroscopic guidance preceded open retrograde iliofemoral endarterectomy. Adjunctive procedures included 18 profundaplasties, eight femorofemoral, nine femoropopliteal, and one femorotibial bypasses. RESULTS: Thirty-three of the 36 cases were initially successful. The three failures were in patients with extensive calcification. The mean follow-up has been 36.4 months, and the patency rate was 80.5% at 3 and 4 years. The four failures noted on follow-up were caused by three common iliac artery stenoses and one iliac system occlusion. The former group was successfully treated with balloon angioplasty/stent, and the latter patient required an aortofemoral bypass. No operative deaths or limb loss occurred in this series. CONCLUSIONS: Retrograde iliofemoral endarterectomy facilitated by balloon angioplasty is a safe, easy-to-perform, and viable option for patients with combined external iliac artery and common femoral artery occlusive disease. Midterm results (36.4 months) are favorable, and most hemodynamic failures are easy to correct with standard endovascular techniques.     

Iliac vessel injury: operative physiology related to outcome

BACKGROUND: Fifty-three patients treated at a level I trauma center with iliac vessel injury were studied to determine if body temperature and acid-base status in the operating room predicts outcome. METHODS: Records were reviewed for demographics, mechanism of injury, body temperature, acid-base status, operative management, and outcome. Statistical methods included Student's t test, odds ratio determination, and chi-square analysis to determine statistical significance. RESULTS: Fifty-three patients (47 male, 6 female) sustained 92 iliac vascular injuries (36 arterial, 56 venous). Mortality was 34%, with 72% of deaths due to shock within 24 hours. Physiologic parameters differed significantly between survivors and nonsurvivors. Odds ratio identified six conditions; the number present predicted outcome. CONCLUSIONS: (1) There are significant differences between initial and final operating room temperature and acid-base status in survivors versus nonsurvivors with iliac vessel injury. Conditions for odds ratio can be calculated and correlated with outcome. (2) A patient with two or more conditions should be considered for an abbreviated laparotomy to allow for reversal of "physiologic failure."     

Carotid and lower extremity arterial disease in patients with renal artery atherosclerosis

BACKGROUND: Atherosclerotic lesions of the carotid and lower extremity arteries may be associated with renal artery stenosis and influence the management of patients with renal artery disease. OBJECTIVE: To document the prevalence and clinical features of carotid and lower extremity arterial disease in patients with renal artery atherosclerosis. METHODS: An analysis of baseline data on 149 patients enrolled in a prospective natural history study of atherosclerotic renal artery stenosis. Patients with at least 1 abnormal renal artery by duplex scanning were eligible. Carotid artery disease was evaluated by duplex scanning, and ankle/brachial indices were used to assess the lower extremity arteries. Disease at each of the 3 arterial sites was classified as mild, moderate, or severe based on the extent of involvement on both sides. Serum urea nitrogen, creatinine, and lipid levels were also measured. RESULTS: Severe renal, carotid, or lower extremity arterial disease was present in 44%, 19%, and 21% of the patients, respectively. There was a trend for patients with increasing degrees of renal artery disease to have increasing degrees of carotid and lower extremity arterial disease. The prevalence of severe carotid artery disease increased from 7% in the mild renal artery group to 28% in the severe renal artery group. Clinical factors that were most predictive of severe disease were elevated apolipoprotein B levels for the renal arteries, high serum urea nitrogen or creatinine levels for the carotid arteries, and smoking for the lower extremity arteries. CONCLUSIONS: There was a strong association between severe renal artery atherosclerosis and severe carotid artery disease. Patients with renal artery disease also had a high prevalence of lower extremity arterial disease. In this patient population, screening for lower extremity arterial disease can be reserved for those with signs or symptoms of peripheral ischemia. Noninvasive carotid screening is justified in patients with renal artery disease to detect asymptomatic lesions that require either immediate surgical treatment or serial follow-up for disease progression.     

Pediatric vascular trauma. Manifestations, management, and sequelae of extremity arterial injury in patients undergoing surgical treatment

Twenty pediatric patients with a mean age of 9.2 years exhibited 21 injuries to arteries of an extremity and underwent operation. Included were 12 iatrogenic injuries and nine non-iatrogenic penetrating injuries. Femoral, brachial, popliteal, radial, axillary, iliac, and tibial arteries were sites of vascular trauma. Long-term follow-up, averaging 36 months, was possible in 14 patients. Postoperative scanograms, digital impedance plethysmographic studies, and bone age roentgenograms were routinely obtained. Limb length disparities greater than 5 mm, extremity blood pressure differentials greater than 10 mm Hg, and bone age retardation were encountered. Proper treatment of pediatric patients with acute arterial injuries of an extremity requires early operative intervention and continuous postoperative follow-up during years of active growth. If chronic arterial insufficiency ensues, arteriographic studies should be obtained and arterial reconstruction undertaken.     

Contemporary management of isolated iliac aneurysms

OBJECTIVE: Because isolated common iliac artery aneurysms are infrequent, are difficult to detect and treat, and have traditionally been associated with high operative mortality rates in reported series, we analyzed the outcomes of operative repair of 31 isolated common iliac artery aneurysms in 21 patients to ascertain morbidity and mortality rates with contemporary techniques of repair. METHODS: A retrospective review study was conducted in a university teaching hospital and a Department of Veterans Affairs Medical Center. Perioperative mortality and operative morbidity rates were examined in 17 men and four women with isolated common iliac artery aneurysms between 1984 and 1997. Ages ranged from 38 to 87 years (mean 69 +/- 8 years). Slightly more than half of the cases were symptomatic, with abdominal pain, neurologic, claudicative, genitourinary, or hemodynamic symptoms. One aneurysm had ruptured and one was infected. There was one iliac artery-iliac vein fistula. All aneurysms involved the common iliac artery. Coexistent unilateral or bilateral external iliac aneurysms were present in four patients; there were three accompanying internal iliac aneurysms. Overall, 52% of patients had unilateral aneurysms and 48% had bilateral aneurysms. Aneurysms ranged in maximal diameter from 2.5 to 12 cm (mean 5.6 +/- 2 cm). No patients were unavailable for follow-up, which averaged 5.5 years. RESULTS: Nineteen patients underwent direct operative repair of isolated iliac aneurysms. One patient had placement of an endoluminal covered stent graft; another patient at high risk had percutaneous placement of coils within the aneurysm to occlude it in conjunction with a femorofemoral bypass graft. Patients with bilateral aneurysms underwent aortoiliac or aortofemoral interposition grafts, whereas unilateral aneurysms were managed with local interposition grafts. There were no deaths in the perioperative period. Only one elective operation (5%) resulted in a significant complication, compartment syndrome requiring fasciotomy. The patient treated with the covered stent required femorofemoral bypass when the stent occluded 1 week after the operation. The patient treated with coil occlusion of a large common iliac aneurysm died 2 years later when the aneurysm ruptured. CONCLUSIONS: Isolated iliac artery aneurysms can be managed with much lower mortality and morbidity rates than aneurysm previously been reported by using a systematic operative approach. Percutaneous techniques may be less durable and effective than direct surgical repair.     

Peripheral arterial injuries: a reassessment

Ninety-four patients with peripheral arterial injuries were subjected to acute repair, negative exploration, or late repair of the complications of the arterial injury (false aneurysm, A-V fistula, and/or limb ischemia). The causes of failure after acute injury include extensive local soft tissue and bony damage, severe concomitant head, chest or abdominal wounding, stubborn reliance on negative arteriograms in patients with probable arterial injury, failure to repair simultaneous venous injuries, or harvesting of a vein graft from a severely damaged extremity. There is a positive correlation between non-operative expectant treatment and the incidence of late vascular complications requiring late arterial repair. Delayed complications of arterial injuries occurred most frequently in wounds below the elbow and knee.     

Significance of myocardial ischemic electrocardiographic changes during dipyridamole stress echocardiography

The aim of this study was to assess the diagnostic and prognostic value of the presence and characteristics of ischemic electrocardiographic (ECG) changes during dipyridamole stress echocardiography. The ECG response in 178 patients with echocardiographic evidence of myocardial ischemia during dipyridamole stress testing was analyzed. ECG changes occurred in 105 patients (59%). Patients with ECG changes had a higher incidence of echocardiographic signs of ischemia at a low dose than patients with an unchanged electrocardiogram (50% vs 23%; p = 0.0002). Three-vessel and/or left main coronary artery disease (CAD) was found in 41% of patients with and in 21% of patients without ECG changes (p = 0.029). During follow-up (33 +/- 19 months), 30 cardiac events occurred: 10 deaths, 6 infarctions, and 14 unstable anginas. Coronary revascularization was performed in 48 patients with and in 17 patients without ECG changes (p = 0.0022). The univariate predictors of cardiac events were: presence of ischemia in > or =4 ECG leads (p = 0.0004), echocardiographic evidence of ischemia at a low dose (p = 0.0062), ST-segment shift on precordial leads (p = 0.0094), family history of CAD (p = 0.0115), coexistence of > or =3 cardiovascular risk factors (p = 0.0156), ST-segment depression (p = 0.0172), and ECG changes during testing (p = 0.0335). At Cox analysis, occurrence of ischemia at a low dose (odds ratio 3.0; 95% confidence interval 1.3 to 6.8) and the presence of ischemia in > or =4 ECG leads (odds ratio 3.5; 95% confidence interval 1.3 to 9.3) had an independent prognostic importance. In conclusion, the presence and characteristics of ischemic ECG changes are associated with more extensive CAD and worse prognostic outlook than are echocardiographic changes alone during dipyridamole stress echocardiography.     

Arterial vascular injuries in hip prosthesis implantation

Implantation of total endoprosthesis (TEP) is an established method for the operative therapy of acute and chronic hip dysfunction. Beside septic complications iatrogenic injuries of the vascular system regularly occur. Immediate and adequate therapy is necessary in order to prevent loss of an extremity or even patients death. We present three patients with major vascular injuries during hip joint operations. In two patients was the external iliac artery and in one the femoral common artery injured. The cases were managed with PTFE- or Dacron-interposition. The problem of vascular injuries associated with the implantation of total hip joint endoprosthesis will be discussed and the avoidable of most vascular lesions is underlined.     

A reevaluation of intraarterial thrombolytic therapy for acute lower extremity ischemia

PURPOSE: This study was performed to clarify the role of intraarterial thrombolytic therapy (IATT) in the management of acute lower extremity ischemia. METHODS: A retrospective review of 77 patients undergoing 84 courses of high-dose regional urokinase IATT from July 1981 to June 1991 was performed. The group included patients with acute thrombosis of lower extremity bypass grafts (n = 48) or native arteries (n = 36), presenting with ischemic but viable limbs, minimal or no motor dysfunction, and an absence of muscle rigor or compartment syndrome. The data were then examined individually by site of thrombosis to evaluate patient selection for IATT. RESULTS: Complete lysis, complications (either distal thromboembolism or bleeding), and early limb loss occurred in 59.5%, 11%, and 6% of infusions, respectively. IATT precluded the need for operative intervention in 49% of acutely ischemic limbs. When surgery was required, successful IATT precisely localized responsible lesions and reduced the magnitude of operation. A subset of 13 patients were identified in whom either no intrinsic abnormality or poor runoff were evident after lysis and were treated with anticoagulation alone. CONCLUSIONS: These data show IATT to be especially suitable for thrombosis of native iliac or femoropopliteal arteries and infrainguinal vein grafts. IATT serves primarily as an adjunct in management of acute lower extremity ischemia. After successful IATT, subsequent therapy can be tailored to the anatomic cause of thrombosis.     

Popliteal artery trauma. Systemic anticoagulation and intraoperative thrombolysis improves limb salvage

OBJECTIVE: This study was conducted to evaluate those factors associated with popliteal artery injury that influence amputation, with emphasis placed on those that the surgeon can control. SUMMARY BACKGROUND DATA: Generally accepted factors impacting amputation after popliteal artery injury include blunt trauma, prolonged ischemic times, musculoskeletal injuries, and venous disruption. Amputation ultimately results from microvascular thrombosis and subsequent tissue necrosis, predisposed by the paucity of collaterals around the knee. METHODS: Patients with popliteal artery injuries over the 10-year period ending November 1995 were identified from the trauma registry. Preoperative (demographics, mechanism and severity of injury, vascular examination, ischemic times) and operative (methods of arterial repair, venous repair-ligation, anticoagulation-thrombolytic therapy, fasciotomy) variables were studied. Severity of extremity injury was quantitated by the Mangled Extremity Severity Score (MESS). Amputations were classified as primary (no attempt at vascular repair) or secondary (after vascular repair). After univariate analysis, logistic regression analysis was performed to identify the independent risk factors for limb loss. RESULTS: One hundred two patients were identified; 88 (86%) were males and 14 (14%) were females. Forty injuries resulted from blunt and 62 from penetrating trauma. There were 25 amputations (25%; 11 primary and 14 secondary). Patients with totally ischemic extremities (no palpable or Doppler pulse) more likely were to be amputated (31% vs. 13%; p < 0.04). All requiring primary amputations had severe soft tissue injury and three had posterior tibial nerve transection; the average MESS was 7.6. Logistic regression analysis identified independent factors associated with secondary amputation: blunt injury (p = 0.06), vein injury (p = 0.06), MESS (p = 0.0001), heparin-urokinase therapy (p = 0.05). There were no complications with either heparin or urokinase. CONCLUSIONS: Minimizing ischemia is an important factor in maximizing limb salvage. Severity of limb injury, as measured by the MESS, is highly predictive of amputation. Intraoperative use of systemic heparin or local urokinase or both was the only directly controllable factor associated with limb salvage. The authors recommend the use of these agents to maximize limb salvage in association with repair of popliteal artery injuries.     

Refining the indications for arteriography in penetrating extremity trauma: a prospective analysis

PURPOSE: Five hundred fourteen consecutive patients with an isolated upper or lower extremity penetrating injury were entered into a prospective study designed to refine the indications for diagnostic arteriography. METHODS: Twenty-two (4%) patients with limb-threatening ischemia who required immediate operation and 23 (4%) who refused arteriography were excluded from subsequent analyses. The remaining 469 patients were classified as being at high, intermediate, or low risk for an arterial injury. RESULTS: Two hundred thirteen patients who were at low risk were observed for 24 hours, discharged, and monitored as outpatients. No delayed complications of an arterial injury developed in any patient in this group. The intermediate-risk group of 151 patients and the high-risk group of 105 patients underwent arteriography. Seventy-seven injuries were identified; 24 were major (limb-threatening) and 53 were minor. Fourteen major injuries required operative repair or transcatheter embolization; the remaining 10 nonocclusive major injuries were observed without sequelae. CONCLUSIONS: By step-down logistic regression only pulse deficit (p < 0.01) and an ankle/brachial or wrist/brachial index less than 1.00 in the injured extremity (p < 0.03) were found to be significant predictors of an arterial injury. The presence of either of these two clinical variables successfully predicted all major arterial injuries. This prospective study supports the proposition that arteriography that is limited only to those patients who have either a pulse deficit or minimum ankle/brachial or wrist/brachial index less than 1.00 successfully detects all significant arterial injuries.     

Results of reconstruction in major pelvic and extremity venous injuries

PURPOSE: Outcome and venous patency after reconstruction in major pelvic and extremity venous injuries was studied. METHODS: We retrospectively reviewed 46 patients with 47 venous injuries. RESULTS: Injuries were caused by penetrating trauma in 37 extremities, blunt trauma in 6 patients, and were iatrogenic in 4 patients. Pelvic veins were injured in 4 patients, lower-extremity veins were injured in 39 limbs in 38 patients, and upper-extremity veins were injured in 4 patients. Concomitant arterial injuries occurred in 37 patients. Venous repairs were mostly of the complex type and included spiral or panel grafts in 15 (32%) reconstructions, interposition grafts or patch venoplasty in 19 (40%) reconstructions, end-to-end and lateral repair in 11 patients, and ligation in 2 patients. Two patients underwent early amputation. Early transient limb edema occurred in 2 patients, and postoperative venous occlusions were documented in 4 patients. Full function was regained in 39 (81%) extremities. No variable, including 4 retrospectively applied extremity injury scores (mangled extremity severity score [MESS], limb salvage index [LSI], mangled extremity syndrome index [MESI], predictive salvage index [PSI]), correlated with outcome. High values on all 4 scores were significantly associated with reexplorations (P <.02), which were done in 8 patients for debridement (5), arrest of bleeding (2), and repair of a missed arterial injury (1). Follow-up of 28 +/- 6 months on 27 patients (57%; duplex scan in 18, continuous-wave Doppler and plethysmography in 9, and venography in 3) showed 1 occlusion 6 weeks after the injury and patency of all other venous reconstructions. CONCLUSION: Reconstructions of major venous injuries with a high rate of complex repairs result in a large proportion of fully functional limbs and a high patency rate. A high extremity injury score predicts the need for reexploration of the extremity. Mostocclusions occur within weeks of injury, and the subsequent delayed occlusion rate is very low.     

Post-transplant changes of segment 4 after living related liver transplantation

Cocaine-induced thrombosis has been reported in the literature; however, its mechanism is not fully understood. Most cases are of small caliber vessels, such as the coronaries and cerebral vasculature. We report a case of a 36-year-old man with signs and symptoms of acute arterial insufficiency in his right lower extremity. At angiography, the right common iliac artery and the popliteal artery were occluded. The patient was successfully treated with thrombolytic therapy. Cocaine-induced thrombosis should be suspected in a patient with history of cocaine abuse who presents with acute arterial insufficiency in an extremity, without an identifiable source.     

Aortic dissection: percutaneous management of ischemic complications with endovascular stents and balloon fenestration

PURPOSE: The purpose of this study was to evaluate endovascular stenting (EVS) and balloon fenestration (BF) of intimal flaps for the management of lower extremity, renal, and visceral ischemia in acute or chronic aortic dissection. METHODS: Twenty-two patients (16 male, 6 female) with a median age of 53 years (range 35 to 77 years) underwent percutaneous treatment for peripheral ischemic complications of 12 type A (five acute, seven chronic) and 10 type B (nine acute, one chronic) aortic dissections. RESULTS: Ten patients had leg ischemia, 13 had renal ischemia, and 6 had visceral ischemia. Sixteen patients were treated with EVS including 11 with renal, 6 with lower extremity, 2 with superior mesenteric artery, and 2 with aortic stents. Three patients had BF of the intimal flap, and three had BF in combination with EVS. Revascularization with clinical success was achieved in all 22 patients. Two patients died 3 days and 13.4 months after the procedure was performed, respectively. Of the remaining 20 patients, 1 is lost to follow-up, and 19 have persistent relief of clinical symptoms. Mean follow-up time is 13.7 months (range 1.1 to 46.5 months). One case was complicated by guidewire-induced perinephric hematoma. CONCLUSION: EVS and BF provide a safe and effective percutaneous method for managing peripheral ischemic complications of aortic dissection.     

Seat belt-related injury to the common iliac artery: case report and review of the literature

Blunt trauma to the common iliac artery is a rare phenomenon. Although seat belt injuries to the abdominal aorta and the carotid artery have been reported, there is only one previous report in the literature of seat belt injury to the common iliac artery. We report a case of common iliac arterial injury directly related to use of the lap belt and not associated with pelvic or lumbar fractures. The literature related to blunt trauma of the common iliac artery is reviewed.     

Salvage angiogenesis induced by adenovirus-mediated gene transfer of vascular endothelial growth factor protects against ischemic vascular occlusion

PURPOSE: Vascular endothelial growth factor (VEGF) is a potent stimulator of angiogenesis, and transgene expression from adenovirus vectors can provide in vivo delivery of proteins. On the basis of this knowledge, we hypothesized that local administration of a replication-deficient adenovirus vector expressing complementary DNA for VEGF (AdVEGF) would induce collateral vessel formation in the setting of ischemia that could protect against subsequent acute vascular occlusion. METHODS: Hindlimb ischemia was induced in Sprague-Dawley rats by means of unilateral ligation of the common iliac artery immediately followed by administration of 4 x 10(9)-plaque-forming units VEGF, the control vector AdNull, or phosphate-buffered saline solution into the iliofemoral adipose tissue and thigh muscles. Untreated rats with common iliac ligation were used as an additional control group. RESULTS: Local VEGF expression was observed for 5 days in AdVEGF-treated rats but not in controls. Three weeks after ligation and vector administration, the ipsilateral femoral artery was ligated for a model of an acute vascular occlusion in the setting of preexisting ischemia. Blood flow to the ischemic hindlimb relative to the contralateral hindlimb evaluated with color microspheres demonstrated significantly increased blood flow in the AdVEGF-treated rats compared with each control group (p < 0.0001). Relative blood flow assessed by means of 99mTc-sestamibi radionuclide scans also demonstrated increased blood flow to the ligated hindlimb of AdVEGF-treated rats compared with each control group (p < 0.002). AdVEGF-treated rats also demonstrated increased vascularity in the ligated limb compared with each control group as assessed by means of angiography (p < 0.0001) and histologic quantification of blood vessels less than 80 microm diameter in local adipose tissue and capillaries per muscle fiber (p < 0.0002). AdVEGF treatment prevented a rise in femoral venous lactate femoral venous concentrations 1 hour after femoral artery ligation in control rats (p < 0.04). CONCLUSIONS: An adenovirus vector expressing VEGF complementary DNA is capable of stimulating an angiogenic response that protects against acute vascular occlusion in the setting of preexisting ischemia, suggesting that in vivo gene transfer of VEGF complementary DNA might be useful in prophylaxis of advancing arterial occlusive disease.     

Mesenteric vascular problems. A 26-year experience

Mesenteric vascular problems are infrequent, but may be catastrophic. During a 26-year period, 55 private patients were treated for the following disorders: (1) 12 patients with visceral artery aneurysms, (2) 8 with celiac compression syndrome, (3) 13 with chronic mesenteric ischemia, (4) 12 with acute mesenteric ischemia, and (5) 10 with mesenteric ischemia associated with aortic reconstructions. Splenic artery aneurysms were managed by excision and splenectomy, while celiac and hepatic had excision with graft replacement. Patients with celiac compression syndrome underwent lysis of the celiac artery. Two patients had compression of both celiac and superior mesenteric artery (SMA). One patient required vascular reconstruction of both arteries for residual stenoses. Patients having chronic mesenteric ischemia were treated with bypass grafts, with one death (7.7% mortality) and good long-term results. Those with acute mesenteric ischemia were treated by SMA embolectomy, bowel resection, or both, with a mortality of 67%. When associated with aortic reconstructions, mesenteric ischemia carried a mortality of 100% if bowel infarction occurred after operation, but when prophylactic mesenteric revascularization was performed at the time of aortic surgery, prognosis was greatly improved, with only one death among six patients. An aggressive approach including prompt arteriography with early diagnosis and surgical therapy is advocated for these catastrophic acute mesenteric problems.