The use of gastric tonometry in the assessment of celiac artery compression syndrome

This report describes the use of gastric tonometry to measure gastric mucosal ischemia/intestinal mucosa pH (pHi) in a patient treated for celiac artery compression syndrome. Significant gastric mucosal ischemia was demonstrated prior to celiac artery decompression as indicated by a pHi of 7.29. The ischemia was relieved by celiac artery decompression, with an increase in the pHi to 7.48. The patient experienced complete relief of his symptoms after surgical decompression and remains asymptomatic 14 months after surgery. Gastric tonometry provides an objective measurement of intestinal perfusion and ischemia in the treatment of celiac artery compression syndrome.

Nicotine and its metabolite cotinine are mitogenic for human vascular smooth muscle cells

PURPOSE

Intimal hyperplasia caused by smooth muscle cell (SMC) proliferation is the major cause of infrainguinal graft failure within the first 12 months. Tobacco smoking is associated with a twofold increase in graft failure within the first year of extremity bypass surgery, but the mechanism is not clearly understood. This study evaluated the effect of nicotine and its major stable metabolite cotinine on vascular SMC proliferation in vitro.

METHODS

SMC were harvested from human arteries and grown in culture with standard methods. Cells were seeded at a density of 1.8 x 10(4) cells/well in 24 multiwell dishes and cell cycle-synchronized. Subsequently the SMC were incubated with media containing 0.1% or 15% fetal bovine serum and nicotine or cotinine at concentrations ranging from 10(-9) mol/L to 10(-6) mol/L. Control samples were incubated with corresponding media but without the drugs. SMC proliferation was determined at 4 days with a cell counter. DNA synthesis was assessed at 24 hours with 3H-thymidine uptake. The results were expressed as a percentage change compared with the control samples (mean +/- SEM). Results were analyzed by analysis of variance and t tests.

RESULTS

In the presence of serum both nicotine and cotinine at concentrations of 10(-7) and 10(-8) mol/L were mitogenic for SMC in vitro (p < 0.05). A weak mitogenic effect was observed at a low serum concentration for cotinine but not nicotine. Cotinine at a concentration of 10(-9) mol/L, a level seen among passive smokers, was a statistically significant stimulus for DNA synthesis in both minimum serum and serum-supplemented media. At high concentrations both substances were toxic for the cells.

CONCLUSION

We have demonstrated a potential role for nicotine and cotinine in the development of intimal hyperplasia and ultimately failure of the vascular reconstruction.

The thrombosed prosthetic graft is a risk for infection of an adjacent graft

BACKGROUND

A bland thrombosed graft may be more susceptible to the future risk of infection than a patent graft. Once infected, that graft can threaten other patent grafts. Therefore, the purpose of the following study was to assess the role a thrombosed graft might play in infection of contiguous patent bypasses.

METHODS

From 1990, a retrospective review was performed using the operative and medical records of cases in which a prosthetic graft infection was identified arising in association with an adjacent thrombosed graft.

RESULTS

A total of 22 cases of prosthetic arterial bypass infection were treated at our institution from January 1990 through September 1995. Of these, 7 (32%) were identified by the operative report as arising in a thrombosed prosthetic graft and spreading to an attached or adjacent patent prosthetic graft. All patients had multiple bypasses prior to infection, mean 5.4 +/- .75 (range 3 to 8). All thrombosed infected grafts were infrainguinal polytetrafluoroethylene (PTFE) for limb salvage: 6 femoralpopliteal and 1 femorotibial. Mean interval time between placement of the primarily infected graft and removal was 14.6 +/- 6.7 months (range 1 to 53). The secondarily infected patent bypasses were inflow procedures to the same limb in 6 cases: 1 aortofemoral, 2 ileofemoral, 2 axillofemoral, and 1 femoral femoral graft. The thrombosed infrainguinal bypass was directly attached to the secondarily infected bypass in 5 cases and near but not attached in 1 case. One secondarily infected prosthetic graft was a femoraldistal bypass placed adjacent to the thrombosed graft. Four patients had above-knee amputations with a clinically bland graft divided at the time of amputation. In these 4 patients and 2 additional cases, wet gangrene or infection was present in the distal extremity prior to the development of prosthetic graft infection. At the point that infection became clinically apparent, the thrombosed graft was removed in all cases and the secondarily infected graft was removed in 4 of 7 cases. Overall mortality was 57%.

CONCLUSIONS

A thrombosed prosthetic graft near a patent prosthetic bypass may become secondarily infected and threaten the patent graft. We recommend total removal of any thrombosed prosthetic graft in proximity to a patent prosthetic bypass when the risk of infection is high or at the time of subsequent amputation for gangrene.

Eleven-year experience with tibiotibial bypass: an unusual but effective solution to distal tibial artery occlusive disease and limited autologous vein

PURPOSE

The absence of sufficient length of suitable autologous vein occasionally prohibits the treatment of severe distal lower extremity arterial occlusive disease with a standard distal bypass originating from the common femoral artery. During the past 11 years, we have therefore selectively performed short distal bypasses originating from the infrapopliteal arteries in patients with limb-threatening ischemia and occlusive lesions limited to the distal tibial and peroneal arteries. This report summarizes our experience with these tibial artery based distal bypasses.

METHODS

Forty-two distal lower extremity arterial bypasses originating from infrapopliteal arteries in 41 patients were performed over an 11-year period. Autologous vein was used as the bypass conduit in all cases. Extensions from a more proximal bypass were excluded.

RESULTS

The primary patency rate of these tibiotibial bypasses was 77% at 1 year and 62% after 5 years. The limb salvage rate after 5 years was 74%. The perioperative mortality rate was low (2%), but the 5-year patient survival rate (64%) was similar to that with more standard lower extremity arterial reconstructive procedures.

CONCLUSIONS

Tibiotibial bypass is an effective limb salvage procedure in carefully selected patients with distal tibial artery occlusive disease and limited autologous vein. It offers a durable means of distal revascularization in circumstances in which a standard operation might not be desirable or possible.