Endovascular treatment of penetrating thoracic outlet arterial injuries

OBJECTIVES

to establish the feasibility of stent-graft treatment of penetrating thoracic outlet arterial injuries.

DESIGN

prospective study.

MATERIALS AND METHODS

forty-one patients with penetrating injuries to the carotid, subclavian and proximal axillary arteries admitted between August 1998 and May 1999 were studied. Patients requiring urgent surgical exploration for active bleeding (n=26) were excluded. Remaining patients underwent arteriography to assess suitability for stent-graft placement. After successful stent-graft treatment clinical and sonographic follow-up were done at 1 month and thereafter 3-monthly.

RESULTS

of the 15 patients considered, 10 patients qualified for stent-graft treatment (seven male, three female, mean age 27 years). The vessels involved were subclavian artery (seven), carotid artery (two) and axillary artery (one). Seven had arteriovenous fistulae and three, pseudoaneurysms. Stent-graft treatment was successful in all 10 patients with no procedure-related complications. On mean follow-up of 7 months no complications were encountered.

CONCLUSION

endovascular treatment shows promise as a treatment modality for thoracic outlet arterial injuries. Long-term follow-up is required for comparison to the results of standard surgical repair.

Surgical treatment of comminuted, displaced fractures of the greater tuberosity of the proximal humerus: a new technique of double-row suture-anchor fixation and long-term results

Conventional techniques of internal fixation of displaced fractures of the greater tuberosity may be insufficient in presence of comminution. A new surgical technique of internal fixation using a double-row of suture-anchors is described. Long-term results of this technique are evaluated in 21 patients with an isolated, displaced and comminuted greater tuberosity fracture at an average of 3.5 years (range 1-5 years) after surgery. The average age of the patients in the study was 51 years (range 17-93 years). Twenty fractures healed without post-operative displacement. The result was rated as excellent in 8, good in 10, satisfactory in 2 and unsatisfactory in 1 patient. Post-operative bicipital impingement in two patients and reaction to fixation material in one patient resulted in persistent, severe pain in the rehabilitation period, necessitating additional surgery.

Morphology of the human internal vertebral venous plexus: a cadaver study after latex injection in the 21-25-week fetus

The morphology of the anterior and posterior internal vertebral venous plexus (IVVP) in human fetuses between 21-25 weeks of gestational age is described. The results are compared to the findings of a previous morphological study of the IVVP in the aged. The morphological pattern of the anterior IVVP in the fetus is very similar with the anterior IVVP in the aged human. In contrast, the posterior IVVP in the fetus lacks the prominent transverse bridging veins that are present in the aged lower thoracic and the lumbar posterior IVVP. The background of these morphological differences is unclear. Maybe the thoracolumbar part of the posterior IVVP is subject to "developmental delay," or the observed differences in the aged may result from functional and age-related factors that trigger this part of the vertebral venous system during (erect) life. The observed age related morphological differences of the posterior IVVP support the concept of the venous origin of the spontaneous spinal epidural hematoma (SSEH).

Endovascular management of traumatic cervicothoracic arteriovenous fistula

BACKGROUND

This study evaluated a single-centre experience with endovascular repair of traumatic arteriovenous fistula in the cervicothoracic region.

METHODS

Endovascular repair of 27 traumatic cervicothoracic arteriovenous fistulas was attempted between August 1998 and December 2001. Patients with active bleeding or end-organ ischaemia were excluded. Follow-up was accomplished with clinical, duplex Doppler and arteriographic evaluation after 1 month and then every 3 months.

RESULTS

Twelve patients with a major vessel injury were treated by stent-graft placement. Vessels involved were the subclavian (eight), common carotid (three) and internal carotid (one) arteries. Subclavian artery side branches were embolized in three of the eight patients. Four patients developed early type 4 endoleaks but all resolved. Treatment with stent-grafts was ultimately successful in all 12 patients. Three patients were lost to follow-up. During mean follow-up of 21 (range 3-36) months, one of the remaining patients developed a graft stenosis. Fifteen patients with minor vessel injuries were treated with arterial embolization. Vessels embolized were subclavian artery branches (four), external carotid artery and branches (seven) and vertebral arteries (four). Successful embolization was accomplished in ten of 15 patients.

CONCLUSION

Endovascular therapy is a promising alternative to surgery for selected patients with cervicothoracic arteriovenous fistula.

Preliminary observations on the co-existence of regulatory peptides in cells of the baboon endocrine pancreas

Immunocytochemical procedures at ultrastructural and light microscopy level revealed, in the Chacma baboon endocrine pancreas, cells which were immunoreactive for glucagon and pancreatic polypeptide (PP). Some D cells were observed to contain secretory granules with both the appearance and immunoreactivity of A cell secretory granules.

Endovascular repair of occluded subclavian arteries following penetrating trauma

PURPOSE

To describe the endovascular repair of 2 subclavian arteries occluded due to penetrating trauma.

CASE REPORTS

Two male patients were admitted with zone-I neck stab wounds. Both were hemodynamically stable and had absent pulses in the ipsilateral upper limb with decreased Doppler pressures. There were no signs of critical ischemia or active bleeding. On arteriography, complete occlusion of the second segment of the left subclavian arteries in both patients was demonstrated. Stent-graft repair and embolectomy under local anesthesia were successfully performed. No procedure-related complications occurred, and both patients were discharged after 2 days. At 1-year follow-up, stent-graft patency was demonstrated in both patients.

CONCLUSIONS

Endovascular repair is a feasible and safe option in the management of occluded subclavian arteries due to penetrating trauma. This may represent another indication for stent-grafting in the expanding role of this technique.

Development, differentiation, and regeneration potential of the Vervet monkey endocrine pancreas

Using immunolabelling techniques, characterization of the Vervet monkey pancreas included a study of both its development and its structure and normal functioning in the adult. We found that PP and somatostatin occurred during development before glucagon. Insulin and all four pancreatic peptides occurred in one of the primordial buds prior to fusion. These finding call into question the suggested contribution of only PP cells by the ventral bud and non-PP cells by the dorsal bud. Co-localization of glucagon and PP was observed extensively with their relative expressions occurring in what appeared to be an organised non-random manner. Cells expressing both glucagon and PP persisted in the adult, together with many other combinations, suggesting an interesting plasticity of endocrine cell differentiation in the adult. Cellophane wrapping of the head of the Vervet monkey pancreas was shown to result in a noticeable increase in duct cell proliferation and endocrine cell volume but no increased replication of endocrine cells. Cells, immunoreactive for pancreatic peptides, were observed to bud from the ducts, suggesting a regeneration of endocrine cell tissue by neogenesis, although it is uncertain whether the duct epithelium contains the only stem cell source of new endocrine tissue. Hopefully, further investigations will elucidate a mechanism by which endocrine cell regenerative capacity can be stimulated in diabetics to overcome their absolute or relative deficiencies of insulin production.

Morphology and endocrine production of cells in the islets of Langerhans of the Chacma baboon

Biopsies of the pancreas head, tail, and uncinate regions of 6 Chacma baboons (Papio ursinus) were processed for ultrastructural and immunocytochemical (ICC) studies using avidin-biotin peroxidase label for light microscopy (LM) and immunogold for electron microscopy (EM). Survey 0.5 micron sections of Spurrs resin embedded tissue revealed areas of suitable islets. Thin 100-nm sections were then cut and stained from the osmicated blocks for ultrastructural studies. For ICC investigations, 1 micron sections were immunolabeled for LM before areas were selected for thin sectioning for ultrastructural immunolabeling. The baboon endocrine pancreas ultrastructure was found to be similar to that of other mammals with minor differences in islet and secretory granule size and shape and in electron opacity of the secretory granule cores. Insulin glucagon, somatostatin and pancreatic polypeptide (PP) producing cells were described. A small number of cells were seen to contain both glucagon and PP and some D cells were observed to contain a few granules with both the appearance and immunoreactivity of A cell secretory granules. Statistical analysis of 100 secretory granule diameters of each of the 4 cell types in 6 baboons revealed significant differences (p less than 0.001) in size between all but those of the A and D cells. The insulin precursor subunit, C-peptide, and the glucagon precursor, glicentin, were each found together with the final hormone product in their respective secretory granules. The precursors were often located toward the periphery of the secretory granule, suggesting that the conversion of precursor to active hormone may be membrane associated. A nonrandom topographical association was observed between A and D cells, suggesting a strong functional implication.

Gliomatosis peritonei: the value of a "second look" operation

The case history of a 10-year-old black girl with gliomatosis peritonei, Grade 0, is presented. The primary tumour was resected and a "second look" operation carried out 3 months later. The glial implants demonstrated distinct circumferential and intra glial fibrosis (resolution). Because the peritoneal implants had undergone resolution, further therapy became unnecessary. We believe gliomatosis peritonei fully justifies a second laparotomy in order to be able to accurately grade the implants. The grade of the peritoneal implants influences the prognosis and therefore determines the type of therapy to be instituted.

Anatomical importance of infrarenal aortic branches in conventional and endovascular surgery: a review

Minimally invasive or catheter-directed, endoluminal stent-graft treatment of abdominal aortic aneurysms (AAA) is a novel and important advance in the armamentarium of the vascular surgeon and interventional therapist. Provided adequate training is available, infrastructure is optimal, and patient selection correct, successful exclusion of AAA can safely and effectively be achieved with low morbidity and mortality by this lesser invasive technique. An important Achilles heel of endovascular repair (EVR) of AAA is back bleeding or endoleak formation due to incomplete sealing or bridging of aortic branches ostia by endoluminal stents. Significant, recurrent, and persistent retroleaks, a topic of clinical interest, are related to either incompletely sealed-off inferior mesenteric and/or lumbar arteries. The optimal method to diagnose and manage these endoleaks is currently in a state of evolution. In the process of stent-graft treatment of AAA, other important aortic branches are also bridged that may potentially present with the sequelae of peripheral ischemia. This review re-emphasizes the anatomical and clinical importance of abdominal aortic branches relevant to conventional aortic surgery and EVR of AAA.

Induction of cell proliferation and differentiation in the pancreas of the adult Vervet monkey (Cercopithecus aethiops): preliminary results

Cellophane wrapping of the adult Syrian golden hamster pancreas has been found to result in ductular cell proliferation leading to islet regeneration. Injection of cytosol from a cellophane-wrapped pancreas into normal or diabetic hamsters evoked a similar response. In view of the therapeutic potential of the active substance in this cytosol, it was decided to investigate whether a similar response could be achieved in a primate. In normal adult Vervet monkey (Cercopithecus aethiops) pancreas, proliferation is seen only rarely in islet cells and occasionally in duct and acinar cells. Immunohistochemical investigation of normal Vervet monkey pancreas (n = 4) and 14 days (n = 2) and 56 days (n = 1) after cellophane wrapping of the Vervet monkey pancreas revealed a slight increase in proliferation of islet and acinar cells and a larger increase in proliferation of duct cells and in total endocrine cell volume. The results suggest that there is a latent developmental capability in the adult primate pancreas.

[Infection of artificial vascular prostheses. Case reports]

Four patients with prosthetic graft infection are presented. In 3 patients infection occurred in a Dacron aortobifemoral graft. In all 4 patients the infection originated at the femoral anastomoses. In 2 patients the entire aortofemoral graft was removed; one patient died of septicaemia and the other required an above-knee amputation. In 1 patient partial removal of the graft limb proved successful after a femorofemoral bypass using an autogenous venous graft. Above-knee amputation was performed in a further patient after removal of an infected axillofemoral graft. Staphylococcus was consistently isolated from the infected grafts in all the patients.

Budd-Chiari syndrome. A report of 3 cases

Three patients with the Budd-Chiari syndrome are presented. This is a rare condition characterized by hepatomegaly, progressive and refractory ascites, distension of the abdominal wall veins, abdominal pain and leg oedema. These features are attributed to congestion of the liver and portal hypertension. The condition has been notoriously difficult to treat medically. Surgical measures are directed towards relieving the liver congestion and lowering pressure in the portal system by portal-systemic shunting operations. In some cases refractory ascites may be treated by peritoneovenous shunting with a Le Veen shunt. In a select group of patients orthotopic liver transplantation has proved to be worth while.