Simplified treatment of vascular lesions using the argon laser

Treatment of mucosal lesions and abnormalities using the carbon dioxide laser is well documented in the dental literature; however, use of the argon laser for the ablation of intraoral vascular malformations is not. This article discusses the argon laser-soft tissue interaction and illustrates by case reports its application in the treatment of vascular lesions.

Experience with penile venous surgery

Venogenic impotence was detected in 37 out of 141 patients who attended our clinic with a complaint of erectile dysfunction. Eighteen patients presented with primary impotence and the rest had progressive secondary impotence. All 37 patients have shown partial or poor response to 60 mg of intracavernosal papaverine. The corporovenous leak (CVL) was diagnosed on the careful workup of dynamic pharmacocavernosometry and cavernosography. Concomitant arterial cause was noted in 10% cases on the basis of penile duplex Doppler ultrasound study. 24 patients in the age group of 23-60 years underwent the penile venous surgery. The CVL was noted in the deep dorsal vein (23 cases), cavernous vein (16) and in the crural vein (2). The operation consisted of deep dorsal vein (DDV) ligation and excision with all tributaries (8 cases) or DDV ligation and excision+cavernous vein ligation (13 cases), through an infrapubic curvilinear incision. One patient had crural vein ligation and corporoplasty through a perineal incision, one had direct corporeal revascularization for associated arteriogenic impotence with venous leak and another had distal spongiolysis and closure of a corporospongiosal shunt. The results were excellent in 11 cases, improved in 6 and 7 had failures. Surgical intervention is effective in CVL in selected cases but limiting factors in the form of increasing age, concomitant arteriogenic cause, significant crural leak, missing tributaries, recurrent venous leak and unknown factors may also be present to prevent total cure.

Surgical treatment of venous leakage: medium-term follow-up

Thirty-eight men aged 26-69 years (mean 58) who failed to achieve a full, sustained erection with intracavernosal injections of papaverine and phentolamine (PIPE) and who had evidence of a venous leak on digital subtraction dynamic cavernosography underwent penile vein ligation. Postoperative follow-up ranged from 7 to 44 months (mean 28). Nineteen patients regained spontaneous erections which would allow intercourse (mean follow-up on these men was 23 months). Of these 19 patients, 5 experienced recurrent loss of potency over a 6- to 17-month period (mean 9 months), 4 of these subsequently responding to intracavernosal therapy. Of the 19 without full erections after ligation, 8 obtained erections which would allow intercourse with intracavernosal injections. Two of these patients subsequently lost their response to injections at 2 and 6 months postoperatively. Eleven men had no benefit from surgery (either with or without injections). Of the total of 27 men with erections allowing intercourse, only 19 made an attempted coitus during the follow-up period. Of 9 men with treatment failure who had undergone repeat cavernosography, 8 had evidence of a persistent leak, usually arising from the cavernosal veins. At the time of this study, 4 men had been re-explored, following which 3 obtained erections with the aid of PIPE. Patients who fail to improve following ligation may benefit from re-investigation and repeat ligation using a different surgical approach.

Obliteration of portal systemic shunts as therapy for hepatic encephalopathy in patients with non-cirrhotic portal hypertension

The effects of obliteration of portal systemic shunts (PSS) in 5 patients with non-cirrhotic hepatic encephalopathy is reported. All patients had a history of disturbance of consciousness for several years, and examinations revealed large PSS, most of which connecting the left gastric vein to the left renal vein. After the obliteration of PSS, portal vein pressure elevated, the shunt ratio of the portal blood flow decreased, the indocyanine green disappearance rate increased, and serum albumin increased. Blood ammonia (NH3) decreased significantly accompanied by disappearance of hepatic encephalopathy. This treatment may open a way to improve the quality of life in patients with large PSS without severe hepatic injury.

[A case of hepatic hydrothorax treated by pleuro-venous shunt]

We reported a successful pleuro-venous shunt operation (Pl-V shunt) for a patient of liver cirrhosis with secondary hydrothorax. A 78-year-old female was admitted to our hospital because of severe dyspnea and palpitation. Chest x-ray film revealed right sided massive pleural effusion. Over several weeks the chest tube drainaged about 1,500 ml of transudative fluid per day. We performed Pl-V shunting and pleural effusion subsequently decreased in amount and dyspnea disappeared. This Pl-V shunting is thought to be useful for such a patient with massive pleural effusion which failed to respond to medical therapy.

Laparoscopic internal spermatic vein ligation: report of a new technique

Over the past 22 months, 51 laparoscopic internal vein ligations have been performed to determine its application and practicality in treating the infertile male with varicoceles. Of the 33 cases available for a follow-up of greater than 6 months, 16 pregnancies are reported. Five patients reporting pregnancies refused to submit a postoperative semenogram. Of the reportable series, 17 of 33 had significant improvement in sperm density (51%), 15 of 33 (45%) in sperm viability, and 15 of 33 (45%) in sperm motility. No major complications were seen and minor complications were few and transient. Morbidity was extremely low. Laparoscopic internal spermatic vein ligations would appear to be a reasonable, practical, and effective method to correct varicoceles.

Surgical treatment of veno-occlusive dysfunction: evaluation of short-term and long-term results

The abnormal venous drainage of the penis is an important cause of erectile dysfunction. Until recently the best choice for treatment was the venous surgery. We studied 21 patients submitted to radical vein ligation due to venous leakage. Their age ranged from 27 to 69 years (mean 53 years). A total of 14 patients evaluated after a mean follow-up of 13 months showed a 64% success rate. At a mean follow-up of 25 months the success rate of the 21 patients operated on, decreased to 38%. Therefore, we concluded that in a long-term follow-up the results are not quite satisfactory, which brings us much concern about the efficacy of the operation.

Successful digital replantation after 42 hours of warm ischemia

Previously, 6 to 10 hr were believed to be an acceptable limit of warm ischemia for successful digital replantation. The longest warm ischemia time ever reported was 33 hr. This report presents successful replantations of two fingers after 42 hr of warm ischemia.

Meticulously restored lumina of injured veins remain patent

We report our experience with 38 major venous injury repairs in 37 patients between January 1981 and December 1989. The injuries were caused by gunshot (n = 27), shotgun (n = 3), knife (n = 5), blunt trauma (n = 1), and dog bite (n = 1). These involved 27 femoral, 10 popliteal, and one brachial veins. Thirty patients had associated major arterial injuries and seven had major long bone fractures. Retrospective analysis yielded two groups. Group I consisted of 17 patients who underwent meticulous restoration of venous lumina ensured by intraoperative postreconstruction venography (IPV) in all patients. Two of these required revision on the basis of IPV findings. Late patency of venous repair was confirmed by postoperative venography (n = 10) or duplex scans (n = 7). All 17 venous repairs were patent (100%). In group II none of the 20 patients (21 veins) underwent IPV. Fifteen of the 20 patients underwent venography and five patients (six veins) underwent duplex scanning after surgery. Eight veins were occluded and 13 (62%) were patent. The difference in patency rates of venous repair between groups I and II was significant (p = 0.02). Three (37.5%) of eight patients with occluded venous repair required delayed fasciotomy, but only 1 (3.4%) of 29 limbs (30 veins) with patent lumina required fasciotomy (p = 0.03). We conclude that meticulous restoration to normal-caliber venous lumina, confirmed by IPV, can achieve high patency and low morbidity rates.

Successful replantation of the lower leg after 42-hour ischemia: case report

A case of right lower-leg replantation after 42-hr ischemia is presented. Revascularization of the other foot with circulatory decompensation after 36-hr ischemia was carried out simultaneously. The replanted lower leg survived. Following its shortening in replantation by 12 cm, right lower-leg lengthening by 8 cm was carried out 1.5 years after replantation with the aid of a distraction apparatus. The locomotor function in both lower extremities recovered.

Long-term results of venous reconstruction after vascular trauma in civilian practice

The natural history of venous reconstruction (VR) in terms of patency and clinical outcome after vascular trauma has not been well documented. This study consists of 32 patients who had VR performed for extremity vascular trauma and were available for long-term assessment (mean follow-up time 49 months, range 6 to 108 months). The types of repair performed were as follows: lateral venorrhaphy (simple repair) (56%), interposition grafting (22%), patch repair (12.5%), and end-to-end repair (9.5%). Seventeen patients underwent venography after the operation with documentation of repair patency in eight patients (46%) and thrombosis in nine (54%). Only two patients had significant clinical edema at follow-up examination. Noninvasive venous evaluation consisted of Doppler ultrasonography, impedance plethysmography, photoplethysmography, and color-flow duplex scanning (CFDS). The photoplethysmography-derived venous refilling time of the injured extremity was 34.9 +/- 16.2 seconds whereas that of the contralateral noninjured extremity was 36.8 +/- 16.1 seconds (p = 0.5). Based on standard criteria for CFDS, 90% of VRs were patent. Eight repairs that were patent in the early postoperative period remained patent on CFDS. Of the nine repairs with early thrombosis, eight were assessed as patent on follow-up CFDS. In conclusion, VR is a durable surgical procedure associated with minimal morbidity, good long-term patency, and preservation of venous competence. The natural history of thrombosed VRs appears to be one of thrombus absorption with recanalization.

A preliminary experience with use of magnetic resonance angiography in assessment of failing lower extremity bypass grafts

BACKGROUND

This study evaluates the ability of magnetic resonance angiography (MRA) to detect hemodynamic failure of lower extremity bypass grafts and questions whether conventional angiography is necessary for this purpose.

METHODS

A prospective surveillance protocol with segmental plethysmography and color flow Doppler scanning has been used to detect hemodynamic graft failure in 110 patients with 120 lower extremity bypass grafts (90 vein, 30 polytetrafluoroethylene). Twenty (17%) bypass grafts fit the criteria for impending failure (drop in ankle/brachial index determination greater than or equal to 0.15; velocity less than 45 cm/sec; focal velocity two to three times mean graft flow). Intraarterial digital subtraction angiography and MRA studies were performed on all 20 grafts.

RESULTS

Intraarterial digital subtraction angiograms showed graft occlusion in two grafts, severe native artery progression in three grafts, graft wall defects in six grafts, and anastomotic strictures in nine grafts. MRA results showed an exact correlation in 15 (75%) of 20 cases. False-positive tests occurred in four cases (20%), and false-negative tests occurred in one case (5%). Common reasons for interpretation error were metallic clips and field-of-view limitations. These problems are preventable. When MRA results were compared with color flow scan data, overall accuracy improved to 95%.

CONCLUSIONS

Our studies suggest that MRA can be useful in graft surveillance and that the need for conventional angiography may be reduced in the future.

Venous injuries of the lower extremities and pelvis: repair versus ligation

Many surgeons advocate repair of venous injuries to prevent the sequelae of venous ligation. Since 1986, we have treated 74 patients with 79 venous injuries of the lower extremity or pelvis. There were 68 men and six women with a mean age of 29.2 years (range, 16-62 years). The mechanisms of injury were gunshot wounds in 61 patients, stab wounds in 11 patients, and shotgun wounds and blunt trauma in one patient each. Forty-eight injuries were treated by ligation; 31 injuries were treated by repair. Repairs included two interposition grafts, eight end-to-end repairs, 16 venorrhaphies, and five vein patches. In addition, we developed a venous injury staging system (VIS), which ranged from grade I (less than 50% laceration) to grade IV (complete interruption with soft-tissue injury). Patient age, mechanism, location of injury, associated injuries, and incidence of arterial injury were not different between the patients treated by ligation and those treated by repair. Patients treated with venous ligation had a greater VIS (mean, 3.45 vs. 2.0), a greater incidence of shock (71% vs. 39%), and higher transfusion requirements (9.23 vs. 4.82 units). Postoperative morbidity rates were identical, however. There was no increase in the need for fasciotomy in patients treated with venous ligation. Eighty-six percent of the patients treated by ligation were totally free of edema at discharge. The others had only mild edema that did not interfere with daily activities at discharge and follow-up. Ligation is a safe alternative to repair in patients with injuries to the lower extremities or pelvis.(ABSTRACT TRUNCATED AT 250 WORDS)

[The application of microanastomoses in the surgical treatment of varicocele]

We operated on 50 patients with varicocele employing microsurgical anastomosis. Clinical results were satisfactory with varicocele disappearing 49 times out of 34 cases. The shunt between a high regimen pressure with a lower one improve the venous drainage of the testis. These new techniques must be selected according to the pathogenic mechanism of varicocele.

[Choice of left gastric vena caval shunt for esophageal varices--its rationale and clinical results]

We have surgically treated esophageal varices, particularly by left gastric vena caval shunt (LGCS) as the first choice in patients with good liver function (n = 40). The correlation between clinical outcomes and preoperative splanchnic hemodynamics, and therapeutical plans were evaluated: 1) Operative mortality was nil with recurrence rate of 15.0% and rebleeding noted in only one case. 2) The liver function according to Child's classification showed no significant changes before and after operation. Survival rate was more than 70% with good rehabilitation rate (over 90%). 3) The presence of hyperdynamic splanchnic circulation (left gastric venous flow and gastric wall microcirculation) lead to successful clinical results. 4) Combined use of sclerotherapy was efficacious in case of persistent and recurrent varices. We conclude that LGCS is successful in treating esophageal varices in the setting of hyperdynamic portal circulation with acceptable liver function.

Long-term effects of percutaneous laser balloon ablation from the canine coronary sinus

BACKGROUND

Radiofrequency catheter ablation of left-sided accessory pathways is becoming the first line of therapy for patients with symptomatic Wolff-Parkinson-White syndrome. Nevertheless, alternative ablation techniques merit development, at least as supplementary modalities for cases in which conventional ablation approaches may prove unsuccessful. We recently reported the short-term results with transcatheter laser balloon ablation from the coronary sinus in a canine model, proving that the procedure is feasible for the potential ablation of left-sided accessory pathways. We now report the effects of percutaneous transcatheter laser balloon ablation in a chronic canine model.

METHODS AND RESULTS

Twenty adult mongrel dogs were studied. After baseline coronary arteriography, left ventriculography, and coronary sinus angiography were obtained, 15 dogs received two or three consecutive laser doses from the coronary sinus of 30-40 W for 15-30 seconds, for a total cumulative energy of 1,200-2,400 J. The five remaining animals underwent a procedure consisting of balloon sham inflation without laser exposure and served as controls. After a mean follow-up of 6 weeks, the angiographic procedures were repeated, and the animals were killed. The mean extent of the fibrotic lesion was 15 mm long, 6 mm wide, and 4.5 mm deep and involved the coronary sinus wall, atrium, and, frequently, the summit of the posterior left ventricular wall. Six animals (four in the study group and two in the control group) showed asymptomatic narrowing of the coronary sinus lumen but always with total angiographic reconstitution due to extensive collateral circulation. The circumflex artery and mitral valve were intact angiographically and histologically in all animals.

CONCLUSIONS

Percutaneous transcatheter laser balloon ablation via the coronary sinus produces a lesion that may be anatomically well suited for left-sided accessory pathway ablation. Although coronary sinus narrowing may occur, adverse physiological effects are unlikely due to the development of extensive collateral circulation. Systematic clinical studies of this new approach to catheter ablation appear warranted.

Effects of surgical repair of experimental left varicocele on testicular temperature, spermatogenesis, sperm maturation, endocrine function, and fertility in rabbits

To evaluate the effectiveness of surgical correction of varicocele in restoring the function of the varicocelized testicle, experimental varicoceles were created in 16 male rabbits by partly ligating the left lumbotesticular trunk. Five control rabbits received a sham operation (group A). Two months later, eight of the varicocelized rabbits underwent surgical repair by ligation and cutting of the dilated left testicular vein (group B). The remaining eight varicocelized animals did not receive any additional treatment (group C). Five months after the initial operation, group C animals had a significantly lower sperm concentration, sperm motility, bilateral testicular androgen-binding protein activity, bilateral testicular vein testosterone concentration, bilateral testicular versus intraabdominal temperature difference, and fertility when compared with groups A and B. These findings suggested that the surgical repair of an experimental varicocele in the rabbit can significantly improve the parameters indicating the harmful effects of the varicocele on the testicles.

[Anatomy of the posterior urethra]

The short section of the urethra that passes through the urogenital diaphragm is termed the membranous urethra. It is accompanied by several vessels and nerve fibers. In surgery on the membranous urethra the perineal body is of crucial importance, and precise knowledge of the course of the urethra through the pelvic floor is essential. Furthermore, the relationship between the membranous urethra and its accompanying structures is of great importance. These include the branches of the internal pudendal artery, the prostatic venous plexus and the cavernous nerves coursing ventrally from the pelvic plexus. The nerves supplying the membranous urethra were studied in fetuses with the help of a magnifying lens. The results of the dissections are documented by histological sections, photographs and paintings.

Transection and devascularization procedures for bleeding from oesophagogastric varices

Transection and devascularization procedures (Sugiura procedure and transabdominal transection of oesophagus and devascularization) had been the most popular modality of treatment for oesophagogastric varices until the 1970s but the trends of treatment for varices have changed drastically during the last decade. This is partly due to the recent development of endoscopic sclerotherapy and partly due to the patient's increasing demand for less invasive treatment. Recently most patients with oesophagogastric varices are treated initially by endoscopic sclerotherapy and surgical treatment is only called for after sclerotherapy has failed.

Prophylaxis of first variceal bleeding

Surgical, endoscopic and pharmacological treatment options are available for prophylaxis of first upper intestinal haemorrhage in cirrhotic patients. Randomized controlled trials have revealed that a prophylactic portocaval shunt operation should not be performed because its beneficial effect on the bleeding rate is outweighed by a slightly increased mortality. Prophylactic portal non-decompressive surgery (mainly gastro-oesophageal vascular disconnection) has been shown to reduce the bleeding rate and mortality in Japanese cirrhotic patients. However, further trials in different populations must confirm this positive effect. beta-blockers have fewer side-effects and are probably more effective for prophylaxis of the first bleed than sclerotherapy, but survival is only marginally influenced. Nadolol is preferable to propranolol. The effect of sclerotherapy is in part related to the technical experience of the physician. Although sclerotherapy has only minor effects on the bleeding rate, it is associated with a trend towards a prolonged survival. This may be caused by non-specific effects. On the basis of the published trials, only preliminary recommendations can be given. Prophylactic treatment may be useful in cirrhotic patients who are at high risk of bleeding. Life quality may be improved with continuous beta-blocker treatment. Some studies suggest that alcoholics with large varices may also profit from regular prophylactic sclerotherapy performed by experienced physicians.

Occlusion of the sagittal sinus in craniectomized rabbits

Most attempts at production of hydrocephalus in experimental animals by obstructing the venous sinuses have failed. In adult humans, venous sinus occlusion usually results in the clinical syndrome of pseudotumor cerebri with small or normal sized ventricles. However, in children less than 18 month old with venous sinus hypertension, ventriculomegaly has been reported. We examined the change in ventricular size in craniectomized animals (simulating children with open sutures) with occlusion of the superior sagittal sinus. New Zealand rabbits weighing 1500-1800 g were anesthetized with an intramuscular injection of 2 ml 7:3 ketamine (100 mg/ml): Rompun (xylazine) (20 mg/ml) solution. The scalp was shaved, prepped with Betadine, and infiltrated with 1% lidocaine, and a midline scalp incision made. The periosteum was reflected laterally and a craniectomy performed with microscopic magnification. The dura was exposed overlying both cerebral hemispheres and the superior sagittal sinus from its origin to the torcular. In five control animals, the scalp was then closed. In ten experimental animals, small incisions were made in the dura just lateral to the superior sagittal sinus with a no. 11 scalpel and then with microscopic magnification the sinus was coagulated with bipolar cautery and transected; the scalp was then closed. All animals were allowed 5-7 days to recover, then ultrasound was used to assess ventricular size. We observed a small but statistically significant increase in ventricular size in the experimental group compared to the control group. This model provides evidence that venous sinus occlusion in animals with expandable crania can produce ventriculomegaly.

Laparoscopic ligation of internal spermatic vein

Laparoscopic procedures have long been a standard form of treatment for gynaecological disorders but have only recently shown promise in the evaluation and treatment of urogenital diseases, such as pelvic lymphadenectomy. We performed laparoscopic ligation of the bilateral internal spermatic veins in 15 male pigs. The average operative time was 20 min and operative morbidity was minimal, comprising mild subcutaneous emphysema around the trocars. Engorgement of the spermatic vein proximal to the endoclip site was noted. There was no operative mortality. Laparoscopic ligation of the internal spermatic veins seems to be a feasible method for the treatment of varicoceles, especially bilateral lesions.

[Massive hemorrhage from presacral veins during resection of the rectum]

During the last 53 abdominoperineal amputations of the rectum for carcinoma, we had to control 5 massive hemorrhages. 4 of which were due to a lesion of the presacral venous plexus and caused a mean blood-loss of 4750 ml. During a "normal" Mile's operation our 49 other patients lost an average of 1750 ml (median 1200 ml) of blood. The negative effects of this type of complication and the following need for massive transfusion is not only local, circulatory and pulmonary, but also due to the immunodepressive effects of massive transfusion. We describe the different methods of control of these hemorrhages and insist on the advantage of using sterilised metallic thumbtacks, a method which was described 1984 by doctor Wang Qinyao of Shanghai.

[Results of deep dorsal vein ligation for venogenic impotence]

We treated seventy venogenic impotence with ligation of the deep dorsal vein of the penis. Their corporal veno-occlusive function was evaluated by dynamic infusion cavernosometry and cavernosography (DICC). Under local anesthesia, we made a longitudinal skin incision at the base of the penis. The deep dorsal vein was ligated and also a portion of this vein of 1.5 cm long was resected together with branches surrounding the vein. After the operation, the infusion rate determined by DICC was confirmed to be decreased in almost all patients. Thirty nine out of seventy cases had their erectile capability restored and reported that they could achieve sexual intercourse. Sixty one of the seventy cases showed full erection together with an intracavernous papaverine injection. However fifty percent of the sixty one patients who became capable of obtaining erection with the treatment had lost their erectile capability again within one year of the operation, however the other fifty percent were shown to maintain their erectile capability for up to three years. As four years after the treatment only thirty percent of those who had achieved the initial erectile capability still remained potent. This operation is easy to perform without any major complications, and its outcome is as good as that achieved by other more invasive venous ligation in the treatment of patients with venogenic impotence. We therefore conclude that penile deep dorsal vein ligation and partial resection of the vein one of the most useful treatments currently available for venogenic impotence and should be the treatment of choice.